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Second Quarter 2019 HCPCS Updates for Texas Medicaid

Last updated on 7/19/2019

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.

On June 27, 2019, TMHP implemented the second quarter 2019 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after July 1, 2019. The HCPCS updates are detailed in this article.

Second Quarter 2019 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes
C9049 C9050 C9051 C9052 J7208 J9030* J9036
* = Rate hearing not required

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, July 1, 2019. 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, 2019, 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, 2019, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

Non-CAD Procedure Codes
90619 C9756*        
CAD Procedure Codes
C9047 C9048 J1444 J7677 J9356 Q5112
Q5113 Q5114 Q5115      
* = Texas Medicaid rate hearing required

New benefits 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 Texas Medicaid adopts the rates. 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.

Restrictions for Procedure Code C9049

Procedure code C9049 will require prior authorization and will be restricted to clients who are two years of age and older.

In fee-for-service, the provider must submit requests for prior authorization for procedure code C9049 to TMHP using the Special Medical Prior Authorization (SMPA) Request Form.

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

Prior Authorization for Procedure Code C9050

Procedure code C9050 will require prior authorization.

In fee-for-service, the provider must submit requests for prior authorization for procedure code C9050 to TMHP using the SMPA Request Form.

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

Age Limitation for Procedure Code C9051

Procedure code C9051 will be a benefit for clients ages eight and older.

Restrictions for Procedure Code C9052

Procedure code C9052 will be a benefit for clients ages 18 and older, and will be restricted to diagnosis code D595.

Diagnosis Restriction for Procedure Code J9030

Procedure code J9030 will be restricted to the following diagnosis codes:

Diagnosis Codes
C670 C671 C672 C673 C674 C675
C676 C677 C678 C679 C7911 D090

Second Quarter 2019 HCPCS Discontinued Procedure Codes

Effective July 1, 2019, CMS will discontinue the following procedure codes:

Procedure Codes
C9042* C9141** C9746*** J9031****

* = Replaced by procedure code J9036

** = Replaced by procedure code J7208

*** = Replaced by informational procedure code 0548T

**** = Replaced by procedure code J9030

Discontinued procedure codes will not be reimbursed after June 30, 2019.

Second Quarter 2019 HCPCS Revised Procedure Code

The description of the following procedure code will be revised:

Procedure Code

J9355

Second Quarter 2019 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

Procedure Codes

0057U

0084U

0085U

0086U

0087U

0088U

0089U

0090U

0091U

0092U

0093U

0094U

0095U

0096U

0097U

0098U

0099U

0100U

0101U

0102U

0103U

0104U

0543T

0544T

0545T

0546T

0547T

0548T

0549T

0550T

0551T

0552T

0553T

0554T

0555T

0556T

0557T

0558T

0559T

0560T

0561T

0562T

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