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Update to ‘First Quarter 2018 HCPCS Updates for the CSHCN Services Program’

Last updated on 11/16/2018

This is an update to the article titled, "First Quarter 2018 HCPCS Updates for the CSHCN Services Program," which was published on this website March 30, 2018.

The following procedure codes have completed the rate hearing process and will be a benefit of the Children with Special Health Care Needs (CSHCN) Services Program for dates of service on or after December 1, 2018:

Procedure Codes

C9464

C9465

C9466

C9467

C9749

Q5103

Q5104

Q9993

Restrictions for Procedure Code C9466

Procedure code C9466 will require prior authorization and will be restricted to clients who are 12 years old and older.

Additional medical necessity criteria will be published in a future notification.

Procedure codes C9466, J2182, J2357, and J2786 may not be billed in any combination for the same date of service by any provider.

Diagnosis Restrictions 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 12 weeks, any provider.

Prior Authorization Requirement for Procedure Code C9749

Procedure code C9749 will require prior authorization.

New Procedure Codes for Infliximab

Procedure codes Q5103 and Q5104 will replace discontinued procedure code Q5102 as follows:

Drug Name

New Procedure Code

Replaces Procedure Code

Inflectra

Q5103

Q5102 with modifier ZB

Renflexis

Q5104

Q5102 with modifier ZC

Procedure codes Q5103 and Q5104 are diagnosis restricted and will be denied when submitted for the same date of service as procedure code J1745, by any provider.

For a list of reimbursable diagnosis codes for infliximab, providers may refer to the current CSHCN Services Program Provider Manual, section 31.2.25.13, “Infliximab.”

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.