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Claims Reprocessing for Procedure Code J1626 When Submitted With Diagnosis Code Z5189

Last updated on 8/9/2018

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.

TMHP has identified an issue with procedure code J1626 for medical services when submitted with diagnosis code Z5189. Claims submitted with dates of service on or after October 1, 2016, might have been denied incorrectly.

Affected claims submitted with dates of service on or after October 1, 2016, might be reprocessed. When the claims are reprocessed, providers might receive additional payment, which will be reflected on Remittance and Status (R&S) Reports.

The current Texas Medicaid Provider Procedures Manual, Clinician Administered Drugs Handbook, subsection 6.1.4 “Nonspecific, Unlisted or Miscellaneous Procedure Codes” that listed the diagnosis code incorrectly as Z1589 will be corrected.

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