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HHSC NOTIFICATIONS 7 Table of ContentsHealth Alert from DSHS: Infant Botulismand History of Honey PacifiersNovember 16, 2018BACKGROUND: Honey can contain spores ofClostridium botulinum, an organism that producesa potent neurotoxin known to cause severe illnessin infants. Infant botulism occurs when C. botulinumspores in food, dust, or other materials are inhaledor ingested and germinate in the gut of infants whohave not yet developed mature intestinal flora. For thisreason, parents are advised not to feed honey (raw orotherwise) to children younger than 12 months old.Infant botulism: Symptoms of botulism in infantsunder 12 months of age typically start with constipationand may include poor feeding and/or weak sucking,weakness, drooping eyelids, loss of head control anddifficulty breathing. Severity can range from mildillness with gradual onset to paralysis, respiratoryfailure, and death. Prompt recognition of a suspectcase, administration of antitoxin, and initiation ofsupportive care can halt progression of the disease.The Texas Department of State Health Services willcoordinate confirmatory testing at the DSHS laboratory.To obtain the antitoxin (Baby BIG) for treatment,physicians can contact the DSHS Emerging and AcuteInfectious Disease Branch or the California InfantBotulism Treatment and Prevention Program.Recent trends: Cases are rare; between 2013 and 2017,Texas has averaged 7 to 8 cases of infant botulismannually. However, since August, four patients havebeen treated for infant botulism and have a historyof using a honey pacifier purchased in Mexico.Investigators noted that these honey pacifiers andother food-containing pacifiers are available forsale at retailers as well as online, and that parentsmay not be aware of their potential danger.Recommendations: Infants (children less than 12months of age) should not be given honey, or pacifierscontaining honey or other food products, because ofthe risk of contracting infant botulism. Consumptionof honey is widely recognized as a risk factor for infantbotulism by healthcare and public health professionals.Infant botulism is a serious illness that requiresurgent medical attention. All suspect cases shouldbe immediately reported to public health officials.For more information, contact DSHS at 512.776.7676.CommunityHealthChoice.org

HHSC NOTIFICATIONS 8 Table of ContentsStanding Order Update for Medicaid Mosquito RepellentAn update to the 2018-19 Texas Medicaid Standing Order for Mosquito Repellent isnow available for use with the Texas Medicaid mosquito repellent benefit. The benefitis for people enrolled in Medicaid (both traditional and managed care) and CHIP.The revised standing order is signed by Dr. Lisa Glenn. The document iseffective Nov. 1 and is valid for one year from the date it was signed. Theprevious standing order signed by Dr. Rajendra Parikh is valid throughOct. 31. Pharmacies may directly obtain a copy of the renewed standingorder upon request by emailing VDP Formulary@hhsc.state.tx.us.Refer to the Mosquito Repellent Benefit for Pharmacies (PDF) for more information: A prescription from a valid healthcare Provider is required for any pharmacy/pharmacist not operating under a standing order, for the dispensingof mosquito repellent to people enrolled in Medicaid or CHIP People enrolled in the Healthy Texas Womenprogram do not require a prescription People enrolled in the CSHCN program require a prescriptionfor mosquito repellent from a healthcare Provider.CommunityHealthChoice.org

HHSC NOTIFICATIONS 9 Table of ContentsFetal Testing Procedure Codes 59020 and59025 Updated Effective January 1, 2019Information posted November 16, 2018Note: Texas Medicaid managed care organizations(MCOs) must provide all medically necessary,Medicaid-covered services to eligible clients.Administrative procedures such as prior authorization,pre-certification, referrals, and claims/encounter datafiling may differ from traditional Medicaid (fee-forservice) and from MCO to MCO. Providers shouldcontact the client's specific MCO for details.Effective for dates of service on or after January 1,2019, the interpretation and technical componentsof fetal testing procedure codes 59020 and 59025will become benefits of Texas Medicaid for femaleclients who are 10 through 55 years old.Procedure codes 59020 and 59025 will beupdated to include the following:Procedure CodeComponentPlace of ServicePayable Provider Types59020*InterpretationOffice, inpatient hospital,outpatient hospitalNurse practitioner (NP),clinical nurse specialist(CNS), physician assistant(PA), physician, andcertified nurse midwife(CNM) ProvidersTechnicalInpatient hospital,outpatient hospitalNP, CNS, PA, physician,CNM ProvidersTotal**Inpatient hospital,outpatient hospitalNP, CNS, PA, physician,CNM ProvidersInterpretation, technicalOffice, inpatient hospital,outpatient hospitalNP, CNS, PA, physician,CNM Providers59025* The total component of procedure code 59020 will remain a benefit in the inpatient and outpatient hospitalsettings. **The total component of procedure code 59025 will also remain a benefit in the office setting.The total and technical components of procedure codes59020 and 59025 will be denied when submitted forthe same date of service as an ambulatory surgicalcenter claim for the same procedure code.Note: New benefts that are adopted by TexasMedicaid must complete the rate hearingprocess to receive public comment on proposedTexas Medicaid reimbursement rates.The total component of procedure codes 59020 and59025 will be denied when submitted for the samedate of service, by the same Provider, as deliveryprocedure code 59410, 59515, 59614, or 59622.After the rate hearing, expenditures must be approvedbefore the rates are adopted by Texas Medicaid.For more information, call the TMHPContact Center at 1.800.925.9126.CommunityHealthChoice.org

HHSC NOTIFICATIONS 10 Table of ContentsProcedure Code T4528 with Modifier U1No Longer a Benefit January 1, 2019Information posted November 16, 2018Note: Texas Medicaid managed care organizations(MCOs) must provide all medically necessary, Medicaidcovered services to eligible clients. Administrativeprocedures such as prior authorization, precertifcation, referrals, and claims/encounter datafling may differ from traditional Medicaid (fee-forservice) and from MCO to MCO. Providers shouldcontact the client's specifc MCO for details.Effective for dates of service on or after January 1, 2019,procedure code T4528 with modifier U1 will no longerbe a benefit of Texas Medicaid or the Children withSpecial Health Care Needs (CSHCN) Services Program.Procedure code T4528 without modifier U1 willremain a benefit of Texas Medicaid and the CSHCNServices Program. Providers may refer to the currentTexas Medicaid Provider Procedures Manual,Durable Medical Equipment, Medical Supplies,and Nutritional Products Handbook, subsection2.2.14.2, “Diapers, Briefs, Pull-ons, and Liners” forbenefit information about procedure code T4528.For more information, call the TMHP Contact Centerat 1.800.925.9126 or the TMHP-CSHCN ServicesProgram Contact Center at 1.800.568.2413.Shingles Vaccine Procedure Code 90750 to Becomea Benefit of Texas Medicaid January 1, 2019Information posted November 16, 2018Note: Texas Medicaid managed care organizations(MCOs) must provide all medically necessary, Medicaidcovered services to eligible clients. Administrativeprocedures such as prior authorization, precertifcation, referrals, and claims/encounter datafling may differ from traditional Medicaid (fee-forservice) and from MCO to MCO. Providers shouldcontact the client's specifc MCO for details.Note: New benefts that are adopted by Texas Medicaidmust complete the rate hearing process to receive publiccomment on proposed Texas Medicaid reimbursementrates. After the rate hearing, expenditures must beapproved before the rates are adopted by Texas Medicaid.For more information, call the TMHPContact Center at 1.800.925.9126.Effective for dates of service on or after January 1, 2019,shingles vaccine procedure code 90750 will becomea benefit for clients who are 50 years of age and olderas follows:Place of ServiceWhen Services are Provided byOfficeNurse practitioner, clinicalnurse specialist, physicianassistant, physician, pharmacy,pharmacist, and certifiednurse midwife ProvidersHomeNurse practitioner, clinical nursespecialist, physician assistant,physician, and federally qualifiedhealth center ProvidersOutpatient hospitalHospital ProvidersOther locationNurse practitioner, clinical nursespecialist, physician assistant,and physician ProvidersCommunityHealthChoice.org

HHSC NOTIFICATIONS 11 Table of ContentsSubstance Use Disorder Benefits to Changefor Texas Medicaid January 1, 2019Information posted November 16, 2018Substance Use Disorder Benefits to Changefor Texas Medicaid January 1, 2019Information posted November 16, 2018Note: Texas Medicaid managed care organizations(MCOs) must provide all medically necessary,Medicaid-covered services to eligible clients.Administrative procedures such as prior authorization,pre-certification, referrals, and claims/encounter datafiling may differ from traditional Medicaid (fee-forservice) and from MCO to MCO. Providers shouldcontact the client's specific MCO for details.Effective for dates of service on or afterJanuary 1, 2019, substance use disorder (SUD)benefits will change for Texas Medicaid.Overview of Benefit ChangesMajor changes to this medical benefitpolicy include the following: Updated benefit language Prior authorization changes Procedure code updates Diagnosis code updatesUpdated Benefit LanguageSUDs are chronic, relapsing medical illnesses that requirean array of best practice medical and psychosocialinterventions of sufficient intensity and duration toachieve and maintain remission and support progresstoward recovery. SUD may include problematic useof alcohol, prescription drugs, illegal drugs (e.g.,cannabis, opioids, stimulants, inhalants, hallucinogens,“club” drugs, other synthetic euphoriants), and othersubstances that may be identified in the future.Treatment for SUD is a benefit of Texas Medicaid forindividuals who meet the criteria for a substancerelated disorder, as outlined in the current editionof the American Psychiatric Association’s Diagnosticand Statistical Manual of Mental Disorders (DSM).SUD treatment services are individualized, ageappropriate medical and psychosocial interventionsdesigned to treat an individual’s problematic use ofalcohol or other drugs, including prescription medication.SUD services may include the following: Withdrawal management services Individual and group SUD counselingin an outpatient setting Residential treatment services Medication assisted treatment Evaluation and treatment (or referral for treatment) forco-occurring physical and behavioral health conditionsLevel of care (e.g., outpatient, residential, inpatienthospital) and specific services provided must adhere tocurrent evidence-based industry standards and guidelinesfor SUD treatment, such as those outlined in the currentedition of the American Society of Addiction Medicine’sTreatment Criteria for Addictive Substance-Relatedand Co-Occurring Conditions, as well as the licensurerequirements outlined in Texas Administrative Code (TAC)Title 25 Chapter 448 pertaining to Standards of Care.SUD treatment services (outpatient or residential)may only be delivered in a licensed chemicaldependency treatment facility (CDTF). Medicationassisted treatment (MAT) may also be delivered byappropriately trained physicians, nurse practitioners(NPs), clinical nurse specialists (CNSs), andphysician assistants (PAs) in the office setting.SUD withdrawal management in an inpatient hospitalsetting may be provided for individuals who meethospital level of care requirements as a result of theseverity of their withdrawal syndrome and/or the severityof their co-occurring conditions. These services maybe reimbursed as general hospital inpatient services.CommunityHealthChoice.org

HHSC NOTIFICATIONS 12 Table of ContentsThe treatment setting and the intensity or level ofservices will vary depending on the severity of theindividual’s SUD and what is clinically appropriate.The intensity or level of services refers to thenumber of hours of services per week, as well asthe types of services the individual receives.Upon admission into a treatment setting, a faceto-face multi-dimensional assessment must beconducted by a qualified credentialed counselor(QCC) or intern as defined in DSHS TAC §448.101to determine a course of treatment that ismedically necessary and clinically appropriate.The assessment must be signed off by a QCC.Evaluation, Treatment, or Referralfor Co-Occurring ConditionsCDTFs shall facilitate access to physical health, mentalhealth, and ancillary services if those services are notavailable through the program and are necessaryto meet treatment goals or individual needs.Individuals in residential CDTFs commonly requiremedications unrelated to their SUD treatment for whichcosts are not covered in the reimbursement for SUDor MAT services. These medications, if included in theMedicaid formulary, may be obtained and reimbursedthrough the individual’s Medicaid pharmacy benefit.Individuals in residential CDTFs also commonly requireother services that are benefits of Texas Medicaid, butnot included in the CDTF rate. Claims for these servicescan be submitted by the appropriate Providers.CDTFs should screen each individual for risk forcontracting tuberculosis, Hepatitis B and C, HIVantibody, and sexually transmitted infections, andif appropriate, provide access to testing and followup. Testing may be performed on site and billed bythe ordering Provider if appropriate testing facilitiesare available that are compliant with the rules andregulations for the Clinical Laboratory ImprovementAmendments (CLIA). Providers that do not complywith CLIA are not reimbursed for laboratory services.Withdrawal Management ServicesWithdrawal management, formerly known asdetoxification, is the medical and behavioraltreatment of individuals experiencing or potentiallyexperiencing withdrawal symptoms as a resultof ceasing or reducing substance use.Withdrawal management involving opioids, alcohol,sedatives, hypnotics, or anxiolytics will vary dependingon the severity of the withdrawal symptoms experiencedbut will typically involve medications to treat symptomsin addition to supportive care, observation, andmonitoring. Withdrawal management involvingstimulants, inhalants, and cannabis typically involvessupportive care, observation and monitoring, andmedications to treat withdrawal symptoms as required.Withdrawal management may be performed in anoutpatient setting for individuals experiencing mild tomoderate withdrawal symptoms that can be successfully,as well as safely, managed outside of a residential settingor an inpatient hospital. Withdrawal management in aresidential setting may be required for individuals whosemultidimensional assessment indicates one or more ofthe following circumstances that would make outpatientwithdrawal management unsafe and/or unsuccessful: A level of severity of withdrawal, medical,and/or mental health complication Sufficient challenges with readiness to change,ability to stop using, and/or social supportWithdrawal management in an inpatient hospital settingmay be required for individuals whose severity of medicalwithdrawal (e.g., impending delirium tremens, severewithdrawal seizures), comorbid medical conditions(e.g., severe liver impairment, acute pneumonia,endocarditis, dementia), and/or comorbid psychiatricconditions (e.g., severe suicidality, acute and unstablepsychosis or mania) requires a hospital level of care.Individual and Group SUD Counselingin an Outpatient SettingCounseling for substance use disorders is designed toassist individuals in developing a better understandingof their SUD, help to establish treatment goals and plansfor achieving those goals, and provide interventionsto assist individuals in accordance with the plan. Theoverall intent of the service is to assist individuals inunderstanding their SUD and developing the skillsand supports needed to address their SUD over time.Counseling may be done individually or in a group settingwith multiple members. Group counseling sessionsare limited to a total of 16 individuals per session.CommunityHealthChoice.org

HHSC NOTIFICATIONS 13 Table of ContentsOutpatient counseling services are appropriate for thefollowing:Residential SUD treatment services may only be providedby a licensed CDTF. Individuals with less severe disordersMedication Assisted Treatment Individuals who are in the early stages of change As a step down from more intensive services Individuals who are stable but for whomongoing monitoring is appropriateNote: For individuals unable or unwilling to accessSUD treatment services at a CDTF, psychotherapydelivered by a licensed practitioner of the healingarts (LPHA) may be an alternative treatmentoption to address an individual’s SUD.Outpatient services may be appropriate at thestart of treatment, throughout treatment, or afteran episode of residential or inpatient treatment,depending on individual acuity, severity, comorbidity,needs, or preferences. Outpatient services canaddress active symptoms as well as provide ongoingtreatment for individuals in partial or full remissionwho need continuing help to maintain progress.Abstinence should not necessarily be a requirementfor participation in outpatient services.Residential Treatment ServicesResidential treatment programs provide a structuredtherapeutic environment where individuals reside withstaff support and deliver comprehensive substanceuse disorder treatment with attention to co-occurringconditions as appropriate. The frequency and durationof services should be based on meeting the individual’sneeds and achieving the individual’s treatment goals.Residential services are appropriate for individualswho require a structured therapeutic environment tostabilize SUD and develop coping and recovery skills.Residential treatment programs may specialize in theunique needs of a specific population such as adolescentsor pregnant or parenting women with children.Episodes of residential treatment may be requiredfor individuals with more severe SUD, moresignific

Continuing Education (CE) Hours TMHP Online Provider Education : Vendor Drug Program Continuing Education for Prescribing Providers : CommunityHealthChoice.org : Claims billed with the delivery codes 59409, . TDI : Provider Services : Provider.CommunityHealthChoice.org 713.295.2295 : Send claims to: