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Advisory 2002-11

"T" Exception Code on TWCC-62 Form
Rule 133.1 (a)(12) - Payment exception codes for reducing or denying payment on a bill

The purpose of this Advisory is to explain and clarify the use of the "T" payment exception code for reducing or denying a payment on a bill. Commission Rules 133.1(a)(12) and 133.304(c) define and require that insurance carriers must use the Commission's payment exception codes to identify the general rationale for reducing or denying payment for a properly completed medical bill. The "T" payment exception code was designed specifically for use when the insurance carrier reduced or denied payment because the treatment or service fell outside the parameters set in the appropriate TWCC treatment guideline and was not sufficiently documented to support the medical necessity of providing the treatment or service outside the parameters.

Article 6 of House Bill 2600 (HB-2600), adopted during the 77 th Texas Legislative Session, 2001, states that treatment guidelines adopted under Chapter 413 of the Texas Labor Code and in effect immediately before September 1, 2001, are abolished on January 1, 2002. Sections 134.1000-134.1003 contain the treatment guidelines referred to by HB-2600. They are: §134.1000, Mental Health Treatment Guideline; §134.1001, Spine Treatment Guideline; §134.1002, Upper Extremities Treatment Guideline; and §134.1003, Lower Extremities Treatment Guideline. These treatment guidelines have been abolished by statute effective January 1, 2002, and have been repealed for purposes of removing them from the Commission rules in the Texas Administrative Code.

The Commission clarifies that, since the Commission's treatment guidelines are abolished and repealed, and until the Commission adopts any new treatment guidelines, the payment exception code "T" is no longer valid and cannot be used to reduce or deny payment by an insurance carrier for dates of service on or after January 1, 2002. It is not appropriate to use the "T" exception code when reducing or denying payment based on Medicare payment policies, proprietary treatment guidelines, or other treatment guidelines. If the Commission adopts treatment guidelines in the future, payment exception code "T" may again be appropriate for use.

Signed this 7th day of August, 2002

Richard F. Reynolds, Executive Director

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