4300, Optional Health Care

4310 HHSC-Established Optional Health Care Services

Revision 23-1; Effective Jan. 5, 2023

Note: For all but APN Services, negotiate rates with providers for optional service procedure codes not listed in the Fee Schedules. For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4311 Advanced Practice Nurse (APN) Services

Revision 23-4; Effective Sept. 22, 2023

An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically a nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM) and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nursing. APN services must be medically necessary and provided within the scope of practice of the APN.

The Medicaid rate for NPs or CNSs reflect 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-ray and injections.

Payment Standard for an NP, CNS and CNM. Use the Fee Schedule for Texas Medicaid Nurse Practitioner/Clinical Nurse Specialist Fee Schedule and Certified Nurse Midwife (CNM), at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for a CRNA. Use the Fee Schedule for Texas Medicaid Certified Registered Nurse Anesthetist (CRNA)/Anesthesiologist Assistant (AA) at www.tmhp.com.

Anesthesia. Use the number of Relative Value Units (RVUs) listed in the Total RVUs column, the conversion factor listed in the Conversion Factor column, and the calculation instructions below.

• Calculate the anesthesia units of time by using the following formula:
  
  Total anesthesia time in minutes divided by 15 = anesthesia units of time.
   
• Calculate the reimbursement for anesthesia services by using the following formula:
  
  Anesthesia units of time plus RVUs multiplied by Conversion Factor = reimbursement amount.
   
• Use 92% of this physician amount to reimburse CRNA services.

Medical, Surgery and Laboratory Services. Proceed as follows:

• Use the amount listed in the age-appropriate Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4312 Ambulatory Surgical Center (ASC) Services

Revision 23-1; Effective Jan. 5, 2023

ASC services must be provided in a freestanding ASC and are limited to items and services provided in reference to an ambulatory surgical procedure. A freestanding ASC service should be billed as one inclusive charge on Form CMS-1500. If more than one procedure code is listed, only the code with the highest HHSC payable amount should be paid.

Payment Standard. Use the Fee Schedule for Texas Medicaid Ambulatory Surgical Center (ASC)/Hospital – Based Ambulatory Surgical Center (HASC)  at www.tmhp.com.

4313 Colostomy Medical Supplies and Equipment

Revision 23-4; Effective Sept. 22, 2023

Colostomy medical supplies and equipment must be medically necessary and prescribed by a physician or advanced practice nurse (APN) within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. The county may require the supplier to receive prior authorization.

Items covered are cleansing irrigation kits, colostomy bags or pouches, paste or powder, and skin barriers with flange (wafers).

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid DMEPOS – TOS 9, E, J, L, And R at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4314 Counseling Services

Revision 23-4; Effective Sept. 22, 2023

Behavioral health services must be medically necessary, based on a physician referral and provided by a licensed clinical social worker (LCSW, previously known as LMSW-ACP), licensed marriage family therapist (LMFT), licensed professional counselor (LPC) or licensed psychologist with a Ph.D. These services may also be provided based on an advanced practice nurse (APN) referral if the referral is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13.

Payment Standard for LCSW, LMFT and LPC. The following procedure codes are covered for Type of Service (TOS) 1 counseling services provided by these providers: 90806, 90847 and 90853 (Current Procedures Terminology (CPT) codes only. The HHSC payable amounts may be accessed in the Texas Medicaid Physician Fee Schedule.

Payment Standard for Ph.D. Psychologist. Use the appropriate Texas Medicaid Outpatient Behavioral Health - Psychologist Fee Schedule at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4315 Dental Care

Revision 23-1; Effective Jan. 5, 2023

Dental services must be medically necessary and provided by a Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD) or Doctor of Dental Medicine (DDM). The county may require prior authorization.

Items covered are an annual routine dental exam, annual routine cleaning, one set of annual X-rays and the least-costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection or extreme pain.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Dental and Orthodontist at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4316 Diabetic Medical Supplies and Equipment

Revision 23-4; Effective Sept. 22, 2023

Diabetic medical supplies and equipment must be medically necessary and prescribed by a physician. These supplies and equipment may also be prescribed by an advance practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. The county may require the supplier to receive prior authorization.

Items covered are test strips, alcohol prep pads, lancets, glucometers, insulin syringes, humulin pens and needles required for the humulin pens.

Insulin syringes, humulin pens, and the needles required for humulin pens are dispensed with a National Dispensing Code (NDC) number and are paid as prescription drugs. They do not count toward the three prescription drugs per month limitation. Insulin and humulin pen refills are prescription drugs (not optional services) and count toward the three prescription drugs per month limitation.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Durable Medical DMEPOS – TOS 9, E, J, L, And R at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4317 Durable Medical Equipment (DME)

Revision 23-4; Effective Sept. 22, 2023

DME must be medically necessary, meet the Medicare and Texas Title XIX Medicaid requirements and be provided under a physician’s prescription. These supplies and equipment may also be prescribed by an advanced practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. Items can be rented or purchased, whichever is the least costly. The county may require the supplier to receive prior authorization.

Items covered are appliances for measuring blood pressure that are reasonable and appropriate, canes, crutches, home oxygen equipment (including masks, oxygen hose and nebulizers), hospital beds, standard wheelchairs and walkers.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid DMEPOS – TOS 9, E, J, L, And R Fee Schedule at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4318 Emergency Medical Services

Revision 23-1; Effective Jan. 5, 2023

Emergency Medical Services (EMS) are ground ambulance transport services. When the person’s condition is life-threatening and requires the use of special equipment, life support systems and close monitoring by trained attendants while enroute to the nearest appropriate facility, ground transport is an emergency service.

Payment Standard. Use the Fee Schedule for Texas Medicaid Ambulance at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

4319 Home and Community Health Care Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary, meet the Medicare and Medicaid requirements and are provided by a certified home health agency.

A plan of care must be recommended, signed and dated by the recipient’s attending physician prior to care being provided.

The county may require prior authorization.

Items covered are registered nurse (RN) visits for skilled nursing observation, assessment, evaluation and treatment, provided that a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered.

Visits made for performing household services are not covered.

The skilled nurse visit is also called an SNV, RN or LVN visit. The Current Procedural Terminology (CPT) code G0154 below includes $10 maximum for incidental supplies used during the visit.

The home health aide visit is also called an HHA visit. The CPT code G0156 below includes incidental supplies used during the visit.

Payment Standard. Use the HHSC Payable below.

4320 Physician Assistant (PA) Services

Revision 23-1; Effective Jan. 5, 2023

PA services must be medically necessary and provided by a PA under the supervision of a physician and billed by and paid to the supervising physician.

Payment Standard. Use the Fee Schedules for Texas Medicaid Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant at www.tmhp.com.

The Medicaid rate for PAs reflects 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-rays and injections.

4321 Vision Care, Including Eyeglasses

Revision 23-1; Effective Jan. 5, 2023

Every 24 months, one examination of the eyes by refraction and one pair of prescribed eyeglasses may be covered. The county may require prior authorization.

Payment Standard for Examination of the Eyes by Refraction. Use the Fee Schedule for Texas Medicaid Optometrist at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for Prescribed Eyeglasses. Use the Fee Schedule for Texas Medicaid Miscellaneous Other Professionals – Optician at www.tmhp.com and proceed as follows:

• Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
• If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4322 Federally Qualified Health Center (FQHC)

Revision 23-1; Effective Jan. 5, 2023

FQHC services must be provided in an approved FQHC by a physician, physician assistant, advanced practice nurse, clinical psychologist or clinical social worker.

Payment Standard. Use the Rate per Visit at Federally Qualified Health Centers.

4323 Occupational Therapy Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 454.

Payment Standard. Use the Fee Schedule for Texas Medicaid Occupational Therapist at www.tmhp.com. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.

4324 Physical Therapy Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 453.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physical Therapist at www.tmhp.com. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.