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Updates to TMPPM and CSHCN Services Program Provider Manual for Genetic Services Reimbursement Criteria for Procedure Codes 99254 and 99255

Last updated on 3/27/2020

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.

Effective for dates of service on or after May 1, 2020, TMHP will update the Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physicians Assistants Handbook, section 5.2.5, “Genetic Evaluation and Counseling by a Geneticist,” and the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual, Physician chapter, section 31.2.22, “Genetics,” to clarify reimbursement criteria for procedure codes 99254 and 99255, which only allows one of the procedure codes to be paid every three years.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.