Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.8 Nonspecific, Unlisted or Miscellaneous Procedure Codes

9.2.39.8
Drugs or biologicals that do not have a unique CPT or HCPCS procedure code must be billed using a nonspecific, unlisted, unclassified, or miscellaneous procedure code. All claims for nonspecific, unlisted, unclassified, or miscellaneous procedure codes are processed manually and must be submitted on paper with accompanying documentation. The billing provider must include the following required documentation:
The claim and attached information will suspend for manual review to determine whether the drug is clinically appropriate based on the information provided and to price the claim using the information provided. Miscellaneous drug or biological procedure codes are reimbursed a percentage of the average wholesale price (AWP). HHSC reserves the option to use other data sources to determine Texas Medicaid fees for drugs when AWP calculations are determined to be unreasonable or insufficient.
The claim will be denied when:
Providers are responsible for administering drugs based on the U.S. Food and Drug Administration (FDA)-approved guidelines. In the absence of FDA indications, a drug needs to meet the following criteria:
The drug is recognized by the American Medical Association Drug Evaluations (AMA-DE), American Hospital Formulary Service Drug Information, the U.S. Pharmacopoeia Dispensing Information, Volume I, or two articles from major peer-reviewed journals that have validated and uncontested data supporting the proposed use for the specific medical condition as safe and effective.
Retrospective review may be performed to ensure documentation supports the medical necessity of the service.
Some injectable medications require prior authorization, which is a condition for reimbursement; it is not a guarantee of payment. To avoid unnecessary denials, the physician must provide correct and complete information, including documentation for medical necessity for the service requested. The physician must maintain documentation of medical necessity in the client’s medical record. Providers may fax or mail prior authorization requests, including all required documentation, to the TMHP Special Medical Prior Authorization Department at:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
Fax: 1-512-514-4213
The following injections in the table below are benefits of Texas Medicaid but are subject to the indicated limitations. Those with an asterisk have more information and can be found listed after the table.
 
Injectable Medication (* indicates more information after table)
Reimbursable Place of Service and Other Limitations or Restrictions
Place of Service: Office, Outpatient Hospital
Prior Authorization Required
Diagnosis Restricted
Ado-trastuzumab entansine (Kadcyla)*
Place of Service: Office, Outpatient Hospital
See Treatment Criteria after table
Place of Service: Office, Outpatient Hospital
Prior Authorization Required
See Treatment Criteria after table
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Office, Outpatient Hospital
Prior Authorization Required for code J7199 only
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Home, Office, Outpatient Hospital
Diagnosis Restrictions: C8441, C8442, C8443, C8444, C8445, C8446, C8447, C8448, C8449, C9140, C9141, C9142
Place of Service: Office, Outpatient Hospital
Prior Authorization Required
Place of Service: Office, Outpatient Hospital
See Treatment Criteria after table
Place of Service: Office, Outpatient Hospital
Diagnosis Restrictions: N3010, N3011
Place of Service: Office, Outpatient Hospital
Diagnosis Restrictions: D588, D591, D593, D594, D595, D596, D598
Place of Service: Office, Outpatient Hospital
Prior Authorization Required
Place of Service: Office, Outpatient Hospital
Diagnosis Restrictions: E7601, E7602, E7603, E761, E76210, E76211, E76219, E7622, E7629, E763, E768, E769
Place of Service: Home, Office, Outpatient Hospital
Diagnosis Restrictions: Z1589, Z510, Z5111, Z5112
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Home, Office, Outpatient Hospital
Diagnosis Restrictions: I480, I481, I482, I483, I484
Place of Service: Office, Outpatient Hospital
Diagnosis Restrictions: E7601, E7602, E7603, E761, E76210, E76211, E76219, E7622, E7629, E763, E768, E769
Place of Service: Home, Office, Outpatient Hospital
Exceptions: J1568, J7504, J7511: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Home (J0202 only), Office, Outpatient Hospital
See Treatment Criteria after table
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Office, Outpatient Hospital
See Treatment Criteria after table
Iron Injections*
Includes: ferric carboxymaltose, iron dextran, iron sucrose, sodium ferric gluconate complex in sucrose, and ferumoxytol
Place of Service: Home, Office, Outpatient Hospital
See Treatment Criteria after table
Leuprolide Acetate (Lupron Depot)*
Place of Service: Office, Outpatient Hospital
See reimbursement limitations after table
Medroxyprogesterone Acetate (Depo Provera)
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Place of Service: Office, Outpatient Hospital
Prior Authorization Required
Place of Service: Home, Office, Outpatient Hospital
Diagnosis Restrictions: C153, C154, C155, C158, C159, C787, C7889
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Thyrotropin alpha for injection (Thyrogen)
Place of Service: Home, Office, Outpatient Hospital
Diagnosis Restrictions: C323, C73, D020, D093, D098, D380, D440, D442, D449, D497, E010, E011, E012, E040, E042, E048, E049, E0500, E0520, Z85850
Place of Service: Office, Outpatient Hospital
See Treatment Criteria after table
Valrubicin sterile solution for intravesical instillation (Valstar)*
Place of Service: Home, Office, Outpatient Hospital
See Treatment Criteria after table
Vitamin B12 (Cyanocobalamin) Injections*
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted
Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim)*
Place of Service: Office, Outpatient Hospital
Diagnosis Restricted

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