Provider Alert! Reimbursement and Audit Notification on Surgical Procedure Codes (last updated July 1, 2021)

Date: July 1, 2021

Attention: All Providers

Subject: 2021-2022 Reimbursement and Audit Notification on Surgical Procedure Codes (last updated July 1, 2021)

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 provide information to providers that TCHP follows the Health and Human Services Commission (HHSC) guidance for outpatient and inpatient surgical procedure reimbursement. Payments for surgical procedure codes include medical devices/implants used for the procedure. All facility services provided in conjunction with the surgery (e.g., laboratory, radiology, anesthesia supplies, and medical supplies) are considered part of the global payment and are not reimbursed separately. Routine X-ray and laboratory services directly related to the surgical procedure are not reimbursed separately. This is in alignment with the Texas Medicaid Provider Procedures Manual (TMPPM), Inpatient and Outpatient Hospital Services Handbook, Section 5.4.2.

There will not be any changes with how the professional services associated with the procedure will be reimbursed. TCHP will follow guidance in the TMPPM, Inpatient and Outpatient Hospital Services Handbook, Section 3.7.4.

In order to more effectively and efficiently ensure claims billing compliance, effective August 1, 2021, TCHP will be fortifying our internal processes. Any facility services provided in conjunction with the surgery (e.g., laboratory, radiology, and anesthesia supplies) will not be reimbursed separately. Additionally, medical supplies/devices/implants will not be reimbursed separately. Examples include, but are not limited to, screws, wires, mesh, etc.

TCHP will be conducting claims audits on the referenced inpatient and outpatient surgical procedures and corresponding billing, in accordance with the Uniform Managed Care Contract (UMCC) §8.1.18.5

Certain pieces of equipment may be reimbursed separately in conjunction with the surgical procedure. Examples of such reimbursable codes include the following:

Next steps for providers: Providers should share this information with their staff and be on the lookout for an audit notification letter.

For additional information, please refer to the TMPPM.

The Texas Medicaid fee schedule is available here: https://public.tmhp.com/FeeSchedules/OnlineFeeLookup/FeeScheduleSearch.aspx

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.