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Third Quarter 2018 HCPCS Updates for Texas Medicaid

Last updated on 9/28/2018

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 September 27, 2018, TMHP implemented the third quarter 2018 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2018. The HCPCS updates are detailed in this article.

Third Quarter 2018 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes

C9033

J0606

J7121

Reminder: The clinician administered drug procedure codes listed in the table above will be added as Medicaid benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, October 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 October 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 October 1, 2018, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

Non-CAD Procedure Codes

C9750

G9978

G9979

G9980

G9981

G9982

G9983

G9984

G9985

G9986

G9987

CAD Procedure Codes

C9034

Q5108

Q5110

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 J0606

Procedure code J0606 will be a benefit for clients who are 18 years old and older and will be restricted to the following diagnosis codes:

Diagnosis Codes

N2581

Z992

Age Restriction for Procedure Code J7121

Procedure code J7121 will be a benefit for clients who are 20 years old and younger.

Third Quarter 2018 HCPCS Revised Procedure Codes

The description of the following procedure codes will be revised:

Procedure Codes

0006U

K0037

Third Quarter 2018 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

Procedure Codes

0045U

0046U

0047U

0048U

0049U

0050U

0051U

0052U

0053U

0054U

0055U

0056U

0057U

0058U

0059U

0060U

0061U

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