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Third Quarter 2019 HCPCS Updates for Texas Medicaid

Last updated on 9/27/2019

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 September 26, 2019, TMHP implemented the third quarter 2019 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2019.

Third Quarter 2019 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes
J0121* J0122 J0222* J0291* J0593 J1096 J1303*
J1943* J1944 J2798* J3031 J3111 J7314 J7401
J9119* J9204* J9210* J9269* J9313*    
* = 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, October 1, 2019. Claims will be denied 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, 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:

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

Non-CAD Procedure Codes
Q4205 Q4206 Q4208 Q4209 Q4210 Q4211 Q4212
Q4213 Q4214 Q4215 Q4216 Q4217 Q4218 Q4219
Q4220 Q4221 Q4222 Q4226      
CAD Procedure Codes
J1097 J7331 J7332 J9118 Q5116 Q5117 Q5118

Age Limitations

Age limitations will apply for the following procedure codes:

Procedure Codes Client Age Limitations
J0121 8 years old and older
J0122, J0222, J0291, J1303, J1943, J1944, J2798, J3031, J9204, J9313 18 years old and older
J0593 12 years old and older
J9269 2 years old and older

Restrictions for Procedure Code J3111

Procedure code J3111 will be a benefit for female clients who are 18 years old and older.

Prior Authorization Requirements

Procedure codes J0222, J9204, J9210, J9269, and J9313 will require prior authorization. Providers may refer to the following subsections in the current Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, for more information about prior authorization criteria:

Procedure Code Clinician-Administered Drug Subsection
J0222 Patisiran (Onpattro) Subsection 43, “Patisiran (Onpattro)”
J9204 Mogamulizumab-kpkc (Poteligeo) Subsection 39, “Mogamulizumab-kpkc (Poteligeo)”
J9210 Emapalumab-Izsg (Gamifant) Subsection 25, “Emapalumab-Izsg (Gamifant)”
J9269 Tagraxofusp-erzs (Elzonris) Subsection 45, “Tagraxofusp-erzs (Elzonris)”
J9313 Moxetumomab pasudotox-tdfk (Lumoxiti) Subsection 41, “Moxetumomab pasudotox-tdfk (Lumoxiti)”

Third Quarter 2019 HCPCS Discontinued Procedure Codes

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

Discontinued Procedure Codes Direct Replacement Procedure Code
C9035 J1943
C9036  J0222
C9037 J2798
C9038 J9204
C9039 J0291
C9040 J3031
C9044 J9119
C9045 J9313
C9048 J1096
C9049 J9269
C9050 J9210
C9051 J0121
C9052 J1303
Procedure Codes
C9043 C9447 J1942 S1090    

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

Third Quarter 2019 HCPCS Revised Procedure Codes

Procedure Codes
J0641 J2794 J7311 J7313 Q4122 Q4165 Q4184

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