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Update to TMPPM for Clinician-Administered Drugs Hematopoietic Injection Limitation

Last updated on 10/15/2019

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.

Beginning December 1, 2019, TMHP will update the Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, 27.1 “Darbepoetin Alfa,” to correct the dosage limitation for procedure codes J0881 and J0882.

Darbepoetin Alfa

Darbepoetin alfa (procedure codes J0881 and J0882) is a erythropoiesis-stimulating protein closely related to erythropoietin. Darepoetin stimulates erythropoiesis by the same mechanism as EPO. Darbepoetin alfa has approximately a three-fold longer half-life than EPO, resulting in a sustained erythopoietic effect and less frequent dosing. Darbepoetin alfa is indicated for:

  • Treatment of anemia associated with chronic renal failure (CRF), including clients on dialysis and clients not on dialysis.
  • Treatment of anemia in clients who have non-myeloid malignancies where anemia is due to the effect of chemotherapy.

Procedure code J0881 must be billed with one of the following diagnosis codes:

Diagnosis Codes

C9000

C9001

C9002

D460

D461

D4621

D46A

D46B

D611

D612

D613

D6189

D619

D630

D631

D644

D6481

D6489

D649

N181

N182

N183

N184

N185

N186

N189

N19

Z5111

Z5112

Procedure code J0882 must be billed with one of the following diagnosis codes:

Diagnosis Codes

D631

N181

N182

N183

N184

N185

N186

N189

N19

Darbepoetin alfa injection is limited to once weekly (Sunday through Saturday).

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