Wednesday, January 18, 2012

Benefit Criteria for Esophageal pH Probe Monitoring

Change for Texas Medicaid

Effective for dates of services on or after April 1, 2011, benefit criteria for esophageal pH probe monitoring will change for Texas Medicaid. Procedure codes 78262, 91034, and 91035 will no longer be diagnosis-restricted.

Provider Type and Place of Service Changes

Surgical procedure codes 91034 and 91035 will be a benefit in the outpatient setting only when performed by a hospital and will no longer be a benefit in the inpatient hospital setting. Procedure codes 91034 and 91035 will no longer be a benefit for ambulatory surgical centers.

Procedure code 78262 will change as follows:

Component : Total Component
Place of Service Changes  : Will no longer be a benefit in the independent laboratory setting.
Provider Type Changes : Independent lab, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based rural health clinic providers will no longer be reimbursed in the office setting.


Component : Interpretation Component
Place of Service Changes  : No place of service changes
Provider Type Changes : Portable X-ray supplier, radiological lab, and physiological lab providers will no longer be reimbursed in the office, inpatient hospital, or outpatient hospital setting.

Component : Technical Component
Place of Service Changes  : Will no longer be a benefit in the home, nursing home, and skilled nursing facility setting.
Provider Type Changes : Radiation treatment center providers will no longer be reimbursed in the office setting.

New Benefits

The interpretation component of procedure codes 91034 and 91035 will be a benefit in the office, inpatient hospital, and outpatient hospital settings when performed by a physician, nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA).

The technical component of procedure codes 91034 and 91035 will be a benefit in the office setting when performed by a portable X-ray supplier, radiological lab, physiological lab, NP, CNS, PA, or physician.


Limitations and Prior Authorization

Procedure codes 78262, 91034, and 91035 will each be limited to two services per rolling year, any provider. Prior authorization will be required for services that exceed two per rolling year. Requests for additional testing may be considered when submitted with documentation of medical necessity that supports, but is not limited to, the following:

1 • Adult’s unintentional weight loss is more than 5 percent of their normal body weight in a span of 12 months or less

2 • Child’s weight loss is 3 to 5 percent of their body mass in less than 30 days

3 • Symptoms of gastroesophageal reflux disease (GERD) that include heartburn and regurgitation that do not respond to treatment with medication

4 • Atypical symptoms of GERD, such as chest pain, coughing, wheezing, hoarseness, and sore throat

Prior authorization requests must be submitted to the Special Medical Prior Authorization Department using the Special Medical Prior Authorization (SMPA) Request Form. The completed prior authorization request form must be maintained by the requesting provider and the prescribing physician. The original, signed copy must be kept by the physician in the client’s medical record.

Claims that are denied for exceeding two services per rolling year may be considered on appeal with documentation of one of the following:

1 • The client is new and the provider has been unsuccessful in obtaining the client’s previous records from a different provider.

2 • The provider is not aware that the client received previous esophageal testing.

Only one appeal will be considered per client, for the same provider. Providers must request prior authorization for any additional esophageal testing performed after the appealed service.

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