Provider Alert! Emergency Room injections/infusions

Date: January 19, 2022

Attention: Emergency Room Facilities

Subject: Emergency Room injections/infusions

Effective Date: February 1, 2022

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 inform emergency room facilities that beginning February 1, 2022 we will reimburse injections/infusions administered during an emergency room visit in accordance with the guidance from the Texas Medicaid Provider Procedures Manual (TMPPM), section 4.2.2, Emergency Department Services. TCHP is required to process and pay Medicaid provider claims in accordance with the benefit limits and exclusions as listed in the TMPPM. Any payments made in error to the facility prior to February 1, 2022 will be recouped in accordance with the Uniform Managed Care Contract § 8.1.18.5. According to the TMPPM, “The administration of an injection may be reimbursed to the provider who administers the injection. The administration of the injection will not be reimbursed to outpatient hospital providers. An injection or infusion administered by a nurse is included in the emergency room charge and is not reimbursed separately to the outpatient facility.”

How this impacts providers: Emergency room revenue codes should be included on ER claims.

The following are reimbursable injection/medication procedure codes: 96370, 96371, 96372, 96373, 96374, 96375, 96376, 96379, 96360, 96361, 96365, 96366, 96367, 96368, and 96369.The procedure codes must accurately reflect the services rendered in the facility’s emergency room.

Next steps for providers: Providers should share this communication with their billing staff. If your facility has received payment that is not in accordance with this provision of the TMPPM expect to see a recoupment of the erroneous payments.

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.