Reimbursement Rates for Some 2018 HCPCS Procedure Codes Will Implement for the CSHCN Services Program

Transcription

1 Reimbursement Rates for Some 2018 HCPCS s Will Implement for the CSHCN Services Program Information posted April 24, 2018 April 17, 2018, the Children with Special Health Care Needs (CSHCN) Services Program reimbursement rates for some 2018 Healthcare Common Coding System (HCPCS) procedure codes will implement for dates of service on or after Jan. 1, for Dates of Service on or after Jan. 1, 2018 Annual Healthcare Common Coding System: Ambulatory surgical center/hospital ambulatory surgical center Anesthesia services Clinical laboratory services Dental services Diagnostic radiology Durable medical equipment Medical services Nonclinical laboratory services Physician administered drugs (non-oncology) Table 1 Physician administered drugs (oncology) Table 2 Physician administered drugs Quarterly HCPCS s Table 3 Surgery and assistant surgery Claims processed before April 17, 2018, with any of these procedure codes for dates of service on or after Jan. 1, 2018, will be reprocessed. Reprocessing may result in increased or decreased payments, which will be reflected on future Remittance and Status Reports. For more information, call the TMHP-CSHCN Services Program Contact Center at

2 Ambulatory Surgical Center/Hospital Ambulatory Surgical Center TOS F/Facility Range Group Number F F $ F F $ F F $1, F F $1, F F $1, F F $1, F F $ F F $ F F $88.39 F F $1, F F $1, F F $1, *Type of Service (TOS): F = Ambulatory Surgical Centers/Hospital Ambulatory Surgical Centers

3 Anesthesia Services TOS Non- Facility (N)/Facilit y (F) Range Base Units Base Fee Adjusted Base Fee (Net of s) N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $0.00 *Type of Service (TOS): 7 = Anesthesia Services

4 Clinical Laboratory Services Clinical Lab Fee Adjusted Clinical Lab Fee Sole Community Hospital Fee Adjusted Sole Community Hospital Fee TOS* Range $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $58.72 $49.32 $60.68 $ $ $ $ $ $58.72 $49.32 $60.68 $ $ $ $ $ $ $ $ $ $ $ $ $ $58.72 $49.32 $60.68 $ $58.72 $49.32 $60.68 $ $ $ $ $ $ $ $ $ $6.56 $5.51 $6.78 $ $11.22 $9.42 $11.59 $ $48.14 $40.44 $49.74 $ $48.14 $40.44 $49.74 $41.78 Type of Service (TOS): 5 = Laboratory

5 TOS* Dental Services (N)/Facility (F) MOD** Range Fee W D5511 N/F $ % $69.74 W D5512 N/F $ % $69.74 W D5611 N/F $ % $69.74 W D5612 N/F $ % $69.74 W D9222 N/F $ % $60.00 W D9222 N/F UZ $ % $83.86 W D9223 N/F $ % $45.00 W D9223 N/F UZ $ % $62.90 W D9239 N/F $ % $58.50 W D9243 N/F $ % $43.88 *Type of Service (TOS): W = Texas Health Steps (THSteps) Dental/Orthodontia, **Modifier: UZ = Special pricing for therapeutic dental (eligibility for enhanced rate is determined by provider qualifications)

6 TOS* Range Facility (N)/ Facility (F) RVU Diagnostic Radiology Fee N/F 0.56 $ $ % $ N/F 0.56 $ $ % $14.97 I N/F 0.26 $ $7.30 0% $7.30 I N/F 0.26 $ $6.95 0% $6.95 T N 0.30 $ $8.42 0% $8.42 T N 0.30 $ $8.02 0% $ N/F 0.86 $ $ % $ N/F 0.86 $ $ % $22.99 I N/F 0.31 $ $8.70 0% $8.70 I N/F 0.31 $ $8.29 0% $8.29 T N 0.55 $ $ % $15.44 T N 0.55 $ $ % $ N/F 1.10 $ $ % $ N/F 1.10 $ $ % $29.40 I N/F 0.40 $ $ % $11.23 I N/F 0.40 $ $ % $10.69 T N/F 0.70 $ $ % $19.65 T N/F 0.70 $ $ % $ N/F 1.18 $ $ % $ N/F 1.18 $ $ % $31.54 I N/F 0.46 $ $ % $12.91 I N/F 0.46 $ $ % $12.30 T N/F 0.72 $ $ % $20.21 T N/F 0.72 $ $ % $ N/F 0.77 $ $ % $ N/F 0.77 $ $ % $20.58 I N/F 0.26 $ $7.30 0% $7.30 I N/F 0.26 $ $6.95 0% $6.95 T N/F 0.51 $ $ % $14.31 T N/F 0.51 $ $ % $ N/F 0.94 $ $ % $ N/F 0.94 $ $ % $25.13 I N/F 0.33 $ $9.26 0% $9.26 I N/F 0.33 $ $8.82 0% $8.82

7 TOS* Range Facility (N)/ Facility (F) RVU Diagnostic Radiology Fee T N/F 0.61 $ $ % $17.12 T N/F 0.61 $ $ % $ N/F 1.10 $ $ % $ N/F 1.10 $ $ % $29.40 I N/F 0.39 $ $ % $10.95 I N/F 0.39 $ $ % $10.42 T N/F 0.71 $ $ % $19.93 T N/F 0.71 $ $ % $18.98 *Type of Service (TOS): 4= Radiology, I = Interpretation Component, T = Technical Component

8 TOS* Durable Medical Equipment Fee (N)/Facility (F) PT** Range J E0953 N/F $ % $ J E0954 N/F $ % $ L3761 N/F $ % $ L7700 N/F $ % $ L8625 F PT- 51 / $1, % $1, J L8625 N/F $1, % $1, L8694 F PT- 51 / $1, % $1, J L8694 N/F $1, % $1, *Type of Service (TOS): 9 = Other Medical Items or Service, J = DME Purchase-New **Proviter Type (PT): 51 = Ambulatory Surgical Center - Freestanding/Independent, 52 = Ambulatory Surgical Center - Hospital Based

9 TOS* Non- Facility (N)/Facil ity (F) Provider Type (PT) /Provider Specialty (PS)** MOD*** Medical Services Range RVU Fee N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F 44 UB 0-20 $ % $ N/F 44 U $ % $ N/F 44 UB $ % $ N/F 44 U $ % $ N/F 65/25 UB 0-20 $ % $ N/F 65/25 U $ % $ N/F 65/25 U $ % $ N/F 65/25 UB $ % $ N/F U $ % $ N/F UB 0-20 $ % $ N/F U $ % $ N/F UB $ % $30.31 *Type of Service (TOS): 1 = Medical Services **Provider Type (PT) /Provider Specialty (PS): 65/25 = Comprehensive Outpatient Rehabilitation Facility/Outpatient Rehabilitation Facility, 44 = Home Health ncy, ***Modifier: U5 = Services provided by licensed therapist, UB = Services provided by therapy assistant

10 (N)/Facility (F) Nonclinical Laboratory Services TOS Range RVU Fee N/F $ $ % $ N/F $ $ % $72.17 I N/F $ $ % $26.66 I N/F $ $ % $25.39 T N/F $ $ % $49.12 T N/F $ $ % $ N/F $ $ % $ N/F $ $ % $25.93 I N/F $ $ % $18.24 I N/F $ $ % $17.37 T N/F $ $ % $8.98 T N/F $ $ % $8.55 *Type of Service (TOS): 5 = Laboratory Services, I = Interpretation Component, T = Technical Component

11 Physician administered drugs (Non Oncology) Table 1 TOS (N)/Facility (F) Modifier Range Fee Effecive Effecive 1 C9015 N/F $ % $ C9029 N/F $ % $ J1555 N/F $ % $ J7211 N/F $ % $ N/F 0-18 Informational only Informational only N/F U $ % $ N/F $ % $20.40 *Type of Service (TOS): 1 = Medical Services

12 TOS Physician administered drugs (Oncology) Table 2 (N)/Facility (F) Range Fee Effecive Effecive 1 C9016 N/F $2, % $2, C9024 N/F $ % $ C9028 N/F $1, % $1, J9203 N/F $ % $ *Type of Service (TOS): 1 = Medical Services

13 Physician Administered Drugs Quarterly HCPCS s Table 3 TOS (N)/Facility (F) Range Fee Effecive Effecive 1 C9492 N/F $ % $ J0565 N/F $ % $ J2350 N/F $ % $ J3358 N/F $ % $ J9285 N/F $ % $ J1627 N/F $ % $ J9023 N/F $ % $79.37 *Type of Service (TOS): 1 = Medical Services

14 TOS (N)/Facility (F) Surgery and Assistant Surgery Range RVU Fee F $ $ % $ F $ $ % $ N/F $ $ % $ N/F $ $ % $ F $ $ % $ F $ $ % $ F $ $ % $ F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ N/F $ $ % $ F $ $ % $ F $ $ % $ N/F $ $ % $ N/F $ $ % $ N $ $3, % $3, F $ $ % $ N $ $2, % $2, F $ $ % $ F $ $1, % $1, F $ $ % $ F 0-20 $ % $ F $ % $ F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $ F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $ F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $286.34

15 Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $ F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $1, % $1, F $ $1, % $1, F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F $ % $ F $ $ % $ F $ $ % $ F $ % $ F $ $ % $ F $ $ % $209.83

16 Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ N $ $1, % $1, F $ $ % $ N $ $1, % $1, F $ $ % $ N $ $1, % $1, F $ $ % $ N $ $1, % $1, F $ $ % $ N $ $ % $ F $ $ % $ N $ $ % $ F $ $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $2, % $2, F $ $2, % $2, F 0-20 $ % $ F $ % $ F $ $2, % $2, F $ $2, % $2, F 0-20 $ % $ F $ % $ F $ $3, % $3, F $ $2, % $2,900.53

17 Surgery and Assistant Surgery TOS (N)/Facility (F) Range RVU Fee F 0-20 $ % $ F $ % $ N $ $2, % $2, F $ $ % $ N $ $2, % $2, F $ $ % $ F $ $1, % $1, F $ $1, % $1, F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ F $ $ % $ F $ $ % $ F 0-20 $ % $ F $ % $ C9738 N 0-20 $ % $ C9738 F 0-20 $ % $ C9738 N $ % $ C9738 F $ % $ C9748 F 0-20 $ % $ C9748 F $ % $ *Type of Service (TOS): 2 = Surgery, 8 = Assistant Surgery