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Clarification to ‘Reimbursement Criteria Updated for Brachytherapy and Therapeutic Radiopharmaceuticals Effective July 1, 2020’

Last updated on 6/17/2020

Information posted June 17, 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.

There is clarification to an article titled “Reimbursement Criteria Updated for Brachytherapy and Therapeutic Radiopharmaceuticals Effective July 1, 2020,” which was published on this website on May 15, 2020.

Reimbursement for each service provided using procedure codes 77321 and 77470 are currently limited to once per two calendar months and will remain the same after July 1, 2020.

Procedure codes 77316, 77317, and 77318 are no longer limited to once per day and no longer limited to one per two months.

Providers may refer to the Centers for Medicare & Medicaid Services (CMS) website at www.medicaid.gov/medicaid/program-integrity/ncci/index.html for the updated Medicaid National Correct Coding Initiative (NCCI) rules, relationships, and general information. A link to the CMS Medicaid NCCI website is also available on the Code Updates – NCCI Compliance web page on TMHP.com.

Providers are encouraged to monitor the CMS website regularly for updates to the Medicaid NCCI rules and guidelines.

Reminder: In instances when medical policy is more restrictive than NCCI or Medically Unlikely Edits (MUE) guidance, medical policy prevails.

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