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Deactivated NCCI MUE Limitations for Substance Use Disorder Treatment and Breast Pump Replacement Parts

Last updated on 5/31/2019

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.

Texas Medicaid has received approval from the Centers for Medicare & Medicaid Services to deactivate the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limitation currently in place for the following substance use disorder treatment and breast pump replacement parts procedure codes for dates of service on or after January 1, 2019:

Procedure Codes

Description

A4281, A4282, A4284, A4286

Breast pump replacement parts

H0005

Group therapy for substance use disorder treatment

Effective June 1, 2019, there will no longer be an MUE limiting H0005 to 1 per date of service. As a reminder, prior authorization for outpatient treatment services beyond the annual limitation of 135 units per calendar year may be considered with documentation supporting medical necessity for continued treatment services.

Effective June 1, 2019, breast pump replacement part procedure codes A4281, A4282, A4284, and A4286 may be reimbursed a maximum of two of each breast pump replacement part when billed on the same date of service, as appropriate for the bilateral nature of the benefit. As a reminder, prior authorization is required for replacement of breast pump parts exceeding the limitation of two of each within a 12-month period.

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