5.6.2.1 Healthcare Common Procedure Coding System (HCPCS)

The procedure coding system used by the CSHCN Services Program is called the Healthcare Common Procedure Coding System (HCPCS). HCPCS is a common coding structure for determining reimbursement made available to health-care providers and third-party payers.

HCPCS is designed around a five-character numeric or alphanumeric base for all procedure codes. To ensure an up-to-date coding structure, HCPCS is updated annually using the latest edition of the Current Procedural Terminology (CPT) manual (i.e., Level I coding) and nationally established Centers for Medicare & Medicaid Services (CMS) codes (i.e., Level II coding). The coding systems comply with Health Insurance Portability and Accountability Act (HIPAA) requirements.

Refer to:

“Level I,” on page 5‑20 and “Level II,” on page 5‑21 for additional information about the HCPCS level coding.

Most added procedure codes that are not directly replacing a discontinued procedure code must go through the Texas Medicaid rate hearing process, as required by Chapter 32 of the Human Resources Code, §32.0282, and Title 1 of the Texas Administrative Code, §355.201, which require public hearings to receive comments on Texas Medicaid payment rates.

Refer to:

Section 5.6.2.5, “Determining Reimbursement Rates for New HCPCS Procedure Codes,” on page 5‑21 for additional information about the rate hearing process as well as claims filing and prior authorization requirements for affected procedure codes.

Specific procedure codes related to program benefits are listed in chapters that follow. These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, procedure codes are added, deleted, or revised. Benefit and coding information is updated in the CSHCN Services Program Provider Bulletin.

The CSHCN Services Program does not reimburse for deleted procedure codes.

Authorization and prior authorization requests must be submitted to update HCPCS procedure codes for services.