Provider Alert! Asthma Education Coverage and Benefits

Date: March 23, 2021

Attention: PCPs and Pulmonologists

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) would like to remind providers of Medicaid and CHIP coverage of asthma education.

How this impacts providers: Asthma education and benefits for Medicaid are covered as described in the Texas Medicaid Provider Procedures Manual (TMPPM). As part of our value added services TCHP offers members enrolled in case management asthma allergy pillow covers to help manage their symptoms. More information is available here: https://www.texaschildrenshealthplan.org/what-we-offer/extra-benefits/health-and-wellness/asthma-allergy-pillow-covers.

Asthma education in the home setting:

• Certified respiratory care practitioners who are physician providers, home health agencies or respiratory therapists may provide asthma education in the home setting.
  • The respiratory care practitioner must be certified by the National Asthma Educator Certification Board (NAECB) as a certified asthma educator
• For a client age 0-20 with a chronic underlying respiratory illness, or a newly diagnosed long-term respiratory condition that is currently resulting in a suboptimal respiratory status, procedure codes S9441 or 98960 are payable for services rendered in the patient’s home with the following limitations:
  • S9441 and 98960 are payable for ages 0-20 only.
  • S9441 and 98960 are each limited to once per day, by any provider, and twice per lifetime.
  • S9441 and 98960 will not be reimbursed in any combination if submitted on the same date of service by any provider.

Source: TMPPM Certified Respiratory Care Practitioner (CRCP) Services Handbook

Group clinical visit for asthma:

—    Physicians, or other qualified health care professionals including Advanced Practice Nurses (NP, CNS) or Physician Assistants (PAs), as well as Registered Nurses in both the office and outpatient hospital setting may provide Group Clinical Visits, for clinical services and educational counseling to a group of clients with asthma.

—    Procedure code 99078 (educational services provided in a group clinical setting visits by physician, or other qualified health care professional) is payable for all ages covered for Texas Medicaid.

—    Group visits must be at least one hour and no longer than 2 hours with a minimum of 2 clients and maximum of 20 clients.

—    Group visits for conditions of asthma are limited to a maximum of four per year for any provider.

—    Group visits are only for established patients and must include CDC-approved Asthma Education and Prevention Programs. Group clinical visits are benefits of Texas Medicaid for the management of the condition of asthma when submitted with the following diagnoses codes:

• J440, J441, J449, J4520, J4521, J4522, J4530, J4531, J4532, J4540, J4541, J4542, J4550, J4551, J4552, J45901, J45902, J45909, J45990, J45991, J45998

Source: TMPPM Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, Chapter 9.2.56.2 Group Clinical Visits and Chapter 9.2.56.3 Group Clinical Visits for Asthma

Asthma education via telemedicine or telehealth
Medicaid MCOs may reimburse for remote delivery of asthma education with modifier 95.

• Medicaid MCOs are prohibited by law from denying reimbursement for an otherwise medically necessary Medicaid covered benefit solely because the service was delivered remotely.
• Remote group clinical visits for asthma education may be billed using 99078 with modifier 95.
• Individual asthma education may be billed using S9441 or 98960 with modifier 95.

CHIP Coverage

• Asthma education is covered by CHIP under Physician/Physician Extender Professional Services.
• CHIP coverage includes remote delivery as telehealth or telemedicine services. CHIP MCOs may reimburse for remote delivery of asthma education with modifier 95.
• A CHIP MCO may choose to cover additional asthma education services as a value-added service.

Additional Information:

• S9441- Asthma education, non-physician provider, per session.
• 98960- Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes.
• 99078- Educational services provided in a group clinical setting visits by physician, or other qualified health care professional.

Resources:
TMPPM

Texas Healthcare Learning Collaborative Portal

DSHS Asthma Program

Next steps for providers: Providers should share this information on asthma coverage and benefits with their staff and utilize the billing information when rendering services to members.
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.

For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.