1/4/2011 TEXAS MEDICAID FEE SCHEDULE - 1 of 4

OUTPATIENT BEHAVIORAL HEALTH - PSYCHOLOGIST

Texas Medicaid Fee Schedule Information

OUTPATIENT BEHAVIORAL HEALTH - PSYCHOLOGIST

This fee schedule is intended to be used by a variety of provider types and provider specialties. Some procedure codes might not apply to every provider
type and provider specialty designated to use the fee schedule. For detailed benefits and limitations, providers should refer to the current year’s Texas
Medicaid Provider Procedures Manual and relevant issues of the Texas Medicaid Bulletin.

Field Descriptions
TOS: One-character type-of-service (TOS) code .
TOS Desc: Description of the TOS.
Proc code: Procedure code.
Mod 1: 1st Modifier, if required for pricing determination.
Mod 2: 2nd Modifier, if required for pricing determination.
Client Age From: From age, if required for pricing determination. This is not the age restriction of the procedure. For procedure codes that
contain more than one pricing row, if the first row is defined by 0-999 age range and the second row is defined by age range 21-
999, the age range for the first row 0-999 is actually for clients 0-20. For procedure codes that contain more than one pricing
row, if the first row is defined by 0-999 age range and the second row is defined by age range 0-20, the age range for the first
row 0-999 is actually for clients 21-999. See the Texas Medicaid Provider Procedures Manual (TMPPM) for exact age
limitations. Correct age ranges will be available in Medicaid fee schedules at a later date.
Client Age Through: Through age, if required for pricing determination. This is not the age restriction of the procedure. For procedure codes that
contain more than one pricing row, if the first row is defined by 0-999 age range and the second row is defined by age range 21-
999, the age range for the first row 0-999 is actually for clients 0-20. For procedure codes that contain more than one pricing
row, if the first row is defined by 0-999 age range and the second row is defined by age range 0-20, the age range for the first
row 0-999 is actually for clients 21-999. See the TMPPM for exact age limitations. Correct age ranges will be available in
Medicaid fee schedules at a later date.
Resource-Based Fee: Texas Medicaid reimbursement methodology (TMRM) payable amount per Title 1 Texas Administrative Code (TAC) §355.8085.
The payable amount for resource-based fees (RBFs) is calculated by multiplying the total relative value units (RVUs) by the
applicable Texas Medicaid conversion factor. For anesthesia services, there is no TMRM payable since the payment amount is
based on the "Total RVUs" (or base units) plus actual face-to-face time units (in 15-minute increments), with that total multiplied
by the appropriate conversion factor. Since CRNAs are reimbursed at 92% of the fee payable to a physician anesthesiologist,
the 92% is applied after the payment amount is calculated and before the payment is processed.

Total RVUs/Base Units: The current RVUs for the procedure code, if the fee is a resource-based fee (RBF). For Anesthesia services, RVUs are actually
base units.
Conv Factor: The Texas Medicaid conversion factor applicable for determining the TMRM payable for RBFs or for determining payment for
anesthesia services.
PPS Fee: Prospective Payment System (PPS) fee.
Access-Based or Max Per 1 TAC §355.8085, fees are either RBFs or access-based fees (ABFs) for physician services or the maximum fee for
Fee: nonphysician services. To calculate the Medicare payable rate for Clinical labs, multiply the access-based or max fee by
104.17%. To calculate the Sole Community hospital rate for clinical labs, multiply the access-based or max fee by
103.35%.

Effective Date: The effective date for total RVUs for RBFs. For fees other than RBFs, the effective date for the PPS, access-based, or max fee.

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
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OUTPATIENT BEHAVIORAL HEALTH - PSYCHOLOGIST

Note Code: Note code indicator. Providers should review each note code to identify specific payment explanation or limitation.
1 In an outpatient setting, this procedure is subject to a 60% payable if diagnosis is nonemergency
2 Clinical Lab Fee Schedule procedure
3 The calculated payable amount for anesthesia could be reduced based on the modifier used
4 There must be medical documentation supporting the need for an inpatient setting
5 This procedure is manually reviewed to determine pricing
6 This procedure is payable only through the CCP program
7 Also available as a Home Health/DME service
8 For APN/PA/CNM providers, the displayed fee reflects 92 percent of the fee
applicable to a physician for the same service
9 For APN/PA/CNM providers, the displayed fee reflects 100 percent of the fee applicable to
a physician for the same service.
12 CRNA providers are reimbursed at 92 percent of the fee applicable to a physician for the same service.
14 For providers of anesthesia services, no fee is displayed since actual payment is based on time spent
with patient in 15-minute increments plus the base units, and that total is multiplied by the conversion factor.
15 Displayed fee reflects reimbursement for the service rendered in a non-facility location.
16 Displayed fee reflects reimbursement for the service rendered in a facility location.
D1 Fee displayed is for a permanent tooth; a primary tooth is paid at 45.83% applied after the
payment amount is calculated and before the payment is processed
D2 Fee displayed is for a permanent tooth; a primary tooth is paid at 80.78% applied after the
payment amount is calculated and before the payment is processed
D3 Fee displayed is for a permanent tooth; a primary tooth is paid at 86.09% applied after the
payment amount is calculated and before the payment is processed
D4 Fee displayed is for a permanent tooth; a primary tooth is paid at 87.76% applied after the
payment amount is calculated and before the payment is processed.
D5 Fee displayed is for a permanent tooth; a primary tooth is paid at 89.82% applied after the
payment amount is calculated and before the payment is processed
D6 Fee displayed is for a permanent tooth; a primary tooth is paid at 91.56% applied after the
payment amount is calculated and before the payment is processed
D7 Fee displayed is for a permanent tooth; a primary tooth is paid at 94.31% applied after the
payment amount is calculated and before the payment is processed
D8 Fee displayed is for a permanent tooth; a primary tooth is paid at 94.79% applied after the
payment amount is calculated and before the payment is processed
E1 Fees for procedures performed by a Licensed Psychological Associate are reduced by 30%

Note Code: P1 - Displayed fee reflects reimbursement for the service rendered in the office setting.
P2 - Displayed fee reflects reimbursement for the service rendered in the home setting.
P3 - Displayed fee reflects reimbursement for the service rendered in the inpatient hospital setting.
P4 - Displayed fee reflects reimbursement for the service rendered in the nursing home (SNF/ICF) setting.
P5 - Displayed fee reflects reimbursement for the service rendered in the outpatient hospital setting.
P6 - Displayed fee reflects reimbursement for the service rendered in the independent laboratory setting.
P7 - Displayed fee reflects reimbursement for the service rendered in the birthing center setting.
P8 - Displayed fee reflects reimbursement for the service rendered in the nursing home (ECF) setting.
P9 - Displayed fee reflects reimbursement for the service rendered in the "other locations" setting.

Total
Client Client RVUs/ Access-
Proc Mod Mod Age Age Resource- Base Conv Based or Note
TOS TOS Desc Code 1 2 From Through Based Fee Units Factor PPS Fee Max Fee Effective Date Codes
MEDICAL
1 SERVICES 90801 0 20 $122.01 4.26 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90801 21 999 $116.20 4.26 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90802 0 20 $131.17 4.58 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90802 21 999 $124.92 4.58 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90804 0 20 $50.69 1.77 $28.640 4/1/2010 8 E1

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
 1/4/2011 TEXAS MEDICAID FEE SCHEDULE - 3 of 4
OUTPATIENT BEHAVIORAL HEALTH - PSYCHOLOGIST

MEDICAL
1 SERVICES 90804 21 999 $48.28 1.77 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90806 0 20 $69.88 2.44 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90806 21 999 $66.55 2.44 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90808 0 20 $102.82 3.59 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90808 21 999 $97.92 3.59 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90810 0 20 $53.56 1.87 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90810 21 999 $51.01 1.87 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90812 0 20 $76.18 2.66 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90812 21 999 $72.55 2.66 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90814 0 20 $110.84 3.87 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90814 21 999 $105.56 3.87 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90816 0 20 $46.11 1.61 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90816 21 999 $43.91 1.61 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90818 0 20 $68.74 2.40 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90818 21 999 $65.46 2.40 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90821 0 20 $101.67 3.55 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90821 21 999 $96.83 3.55 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90823 0 20 $49.83 1.74 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90823 21 999 $47.46 1.74 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90826 0 20 $72.75 2.54 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90826 21 999 $69.28 2.54 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90828 0 20 $105.40 3.68 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90828 21 999 $100.38 3.68 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90847 0 20 $85.63 2.99 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90847 21 999 $81.56 2.99 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90853 0 20 $25.20 0.88 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90853 21 999 $24.00 0.88 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 90857 0 20 $28.07 0.98 $28.640 4/1/2010 8 E1
MEDICAL
1 SERVICES 90857 21 999 $26.73 0.98 $27.276 4/1/2010 8 E1
MEDICAL
1 SERVICES 95873 0 20 $39.52 1.38 $28.640 4/1/2010 12 8
MEDICAL
1 SERVICES 95873 21 999 $37.64 1.38 $27.276 4/1/2010 12 8

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.
 1/4/2011 TEXAS MEDICAID FEE SCHEDULE - 4 of 4
OUTPATIENT BEHAVIORAL HEALTH - PSYCHOLOGIST

MEDICAL
1 SERVICES 95874 0 20 $37.52 1.31 $28.640 4/1/2010 12 8
MEDICAL
1 SERVICES 95874 21 999 $35.73 1.31 $27.276 4/1/2010 12 8
5 LABORATORY 96101 0 999 $115.00 9/1/2007
5 LABORATORY 96110 0 999 $10.31 0.36 $28.640 1/1/2009 E1
5 LABORATORY 96111 0 999 $104.54 3.65 $28.640 1/1/2009 E1
MEDICAL
1 SERVICES 96116 0 20 $72.75 2.54 $28.640 4/1/2010 E1
MEDICAL
1 SERVICES 96116 21 999 $69.28 2.54 $27.276 4/1/2010 E1
MEDICAL
1 SERVICES 96118 0 20 $79.91 2.79 $28.640 4/1/2010
MEDICAL
1 SERVICES 96118 21 999 $76.10 2.79 $27.276 4/1/2010
MEDICAL
1 SERVICES H0050 0 999 $26.93 10/1/2009

Due to AMA/ADA copyright restrictions, CPT and CDT procedure code and modifier descriptions cannot be published in this document.