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December 2016 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 6 Renal Dialysis Facility : 6.2 Services, Benefits, Limitations, and Prior Authorization : 6.2.9 Laboratory and Radiology Services : 6.2.9.4 Hematopoietic Injections

6.2.9.4
Medicaid reimbursement is allowed for hematopoietic injections that are administered to clients who have anemia that is associated with chronic renal failure.
Providers must submit the client’s most recent dated hemoglobin or hematocrit levels in the comments section of the claim form when billing with procedure code Q4081. Frequency and quantity limitations apply.
Refer to:
Subsection 9.2.39.20, “Hematopoietic Injections” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about benefit and limitation criteria.

Texas Medicaid & Healthcare Partnership
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