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Second Quarter 2018 HCPCS Updates for Texas Medicaid

Last updated on 6/29/2018

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

On June 28, 2018, TMHP implemented the second quarter 2018 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after July 1, 2018. The HCPCS updates are detailed in this article.

Second Quarter 2018 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes
C9030 C9462   C9463 C9468   Q9991 Q9992 Q9993
Q9995            

Reminder: The clinician administered drug procedure codes listed in the table above will be added as Medicaid benefits of the Centers for Medicare & Medicaid Services (CMS) effective date, July 1, 2018. Claims will deny until a rate is implemented, but affected claims will be reprocessed back to the CMS effective date. The procedure codes will be payable at the July 1, 2018, published rate until the HHSC rate hearing is held, as required by the Texas Administrative Code 355.201.

Providers may also refer to the following website for details related to rate hearings: www.hhs.texas.gov/about-hhs/communications-events/meetings-events

Effective July 1, 2018, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

Non-CAD Procedure Codes
90750*  Q9994          
* = Texas Medicaid rate hearing required
CAD Procedure Codes
C9031 C9032  Q5105  Q5106      

Note: Procedure code C9032 will be become a benefit at a later date. Benefit information, including the effective date, will be published in a future notification.

New benefits that are adopted by Texas Medicaid must complete the rate hearing process to receive public comment on proposed Texas Medicaid reimbursement rates.

After the rate hearing, expenditures must be approved before the rates are adopted by Texas Medicaid. Providers will be notified in a future banner message or notification if a proposed reimbursement rate will change or if a procedure code will not be reimbursed because the expenditures are not approved.

Limitations for Procedure Code Q9993

Procedure code Q9993 will be restricted to the following diagnosis codes:

Diagnosis Codes
M170 M1711 M1712 M172 M1731 M1732 M174
M175            

Procedure code Q9993 will be limited to one per twelve weeks, any provider.

Note: Procedure code Q9993 will replace discontinued procedure code C9469.

Second Quarter 2018 HCPCS Discontinued Procedure Codes

Effective July 1, 2018, CMS will discontinue the following procedure codes:

Procedure Codes

0004U

0015U

C9469

Note: Discontinued procedure code C9469 will be replaced by procedure code Q9993.

Discontinued procedure codes will not be reimbursed after June 30, 2018.

Second Quarter 2018 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

Procedure Codes
0011M 0012M 0013M 0035U 0036U 0037U 0038U
0039U 0040U 0041U 0042U 0043U 0044U 0508T

For more information, call the TMHP Contact Center at 800-925-9126.