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|
|* = 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: www.hhs.texas.gov/about-hhs/communications-events/meetings-events
Effective October 1, 2019, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:
|Non-CAD Procedure Codes|
|CAD Procedure Codes|
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|
Discontinued procedure codes will not be reimbursed after September 30, 2019.
Third Quarter 2019 HCPCS Revised Procedure Codes
For more information, call the TMHP Contact Center at 800-925-9126.