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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.3 Coding : 6.3.3 Procedure Coding : 6.3.3.1 HCPCS Updates

6.3.3.1
TMHP updates HCPCS codes on both an annual and quarterly basis. Major updates are made annually and minor updates are made quarterly.
Most of the procedure codes that do not replace a discontinued procedure code must go through the rate hearing process. HHSC conducts public rate hearings to provide an opportunity for the provider community to comment on the Medicaid proposed payment rate, as required by Chapter 32 of the Human Resources Code, §32.0282, and Title 1 of the Texas Administrative Code, §355.201.
6.3.3.1.1
Annual HCPCS updates apply additions, changes, and deletions that include the program and coding changes related to the annual HCPCS, Current Dental Terminology (CDT), and CPT updates. These updates ensure that the coding structure is up-to-date by using the latest edition of the CPT and the nationally established HCPCS codes that are released by CMS.
6.3.3.1.2
Quarterly HCPCS updates apply HCPCS additions, changes, and deletions that are released by CMS.
6.3.3.1.3
HHSC holds rate hearings for new HCPCS codes on a regular basis. Rate hearings are announced on the HHSC website at www.hhsc.state.tx.us.
Claims for services that are provided before the rates are adopted through the rate hearing process are denied as pending a rate hearing (EOB 02008) until the applicable reimbursement rate is adopted. The client cannot be billed for these services.
Providers are responsible for meeting the initial 95-day filing deadline. Providers must submit the procedure codes that are most appropriate for the services provided, even if the procedure codes have not yet completed the rate hearing process and are denied by Texas Medicaid as pending a rate hearing.
Once the reimbursement rates are established in the rate hearing and applied, TMHP automatically reprocesses affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.
Refer to:
Subsection 5.11, “Guidelines for Procedures Awaiting Rate Hearing” in “Section 5: Fee‑for‑Service Prior Authorizations” (Vol. 1, General Information) for more information about the authorization guidelines for procedure codes that are awaiting a rate hearing.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.