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Second Quarter 2020 HCPCS Updates for Texas Medicaid

Last updated on 6/30/2020

Information posted June 30, 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.

On June 25, 2020, TMHP implemented the second quarter 2020 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after July 1, 2020.

Second Quarter 2020 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes
C9061 J0223 J0691*
J0742 J0791* J0896
J1201 J1429 J1558
J3399 J7169* J7204
J9177 J9246 J9358
Q5119 Q5120  

Procedure codes noted with an asterisk in the table above will not require a rate hearing.

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, July 1, 2020. Claims will deny 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 July 1, 2020, 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:  

The following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

CAD Procedure Codes
C1748 C9059 C9063
C9122 J0591 J7333
J9198 Q5121  


Non-CAD Procedure Codes
C1849 C9759* C9760
C9762* C9763* C9764*
C9765* C9766* C9767*
G2170* G2171* Q4227
Q4228 Q4229 Q4230
Q4231 Q4232 Q4233
Q4234 Q4235 Q4236
Q4237 Q4238 Q4239
Q4240 Q4241 Q4242
Q4244 Q4245 Q4246
Q4247 Q4248  

Procedure codes noted with an asterisk in the table above will require a Texas Medicaid rate hearing.

Age Limitations

Age limitations will apply for the following procedure codes:

Procedure Codes Client age limitations
J1201 6 months of age and older
J3399 24 months of age or younger
J1558 2 years of age and older
J0791 16 years of age and older
J0223, J0691, J0742, J0896, J7169, J9177, J9246, J9358, Q5119, Q5120 18 years of age and older

Diagnosis Restrictions 

Procedure code J0223 will be restricted to diagnosis codes E8020, E8021, and E8029.

Procedure code Q5120, which is the biosimilar to pegfilgrastim, will also be diagnosis restricted. Providers may refer to the current Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, subsection 22, “Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim,” for a list of payable diagnosis codes.

Prior Authorization Requirements 

Procedure code J0791 is a replacement for discontinued procedure code C9053, and will have the same prior authorization requirements. 

Refer to: The article titled, "Prior Authorization Criteria for Crizanlizumab-tmca (Adakveo) Effective July 1, 2020," which was published on this website June 5, 2020,” for the prior authorization requirements for procedure code J0791.

Onasemnogene abeparvovec-xioi (procedure code J3399) will require prior authorization. Claims for onasemnogene abeparvovec-xioi (Zolgensma) must no longer be submitted with unlisted procedure code J3590.

Refer to: The current Texas Medicaid Provider Procedures Manual, Clinician-Administered Drugs Handbook, subsection 44, “Onasemnogene abeparvovec-xioi (Zolgensma),” for the prior authorization requirements.

JW Modifier for Unused Portions

The following procedure codes may be submitted with modifier JW for consideration of reimbursement for the unused portion of a clinician-administered drug:

Procedure Codes
C9061 J0223 J0791
J0896 J1201 J1429
J7204 J9177 J9246
J9358 Q5119  

Specimen Collection for Coronavirus Testing

Effective for dates of service on or after March 1, 2020, procedure code C9803 will be a benefit of Texas Medicaid, the Healthy Texas Women program, and the state-funded Family Planning Program. 

Once expenditures are approved, TMHP will automatically reprocess affected claims after March 1, 2020. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete.

Services provided before expenditures are approved will be denied with an explanation of benefits (EOB) 02008, “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.”

Second Quarter 2020 HCPCS Discontinued Procedure Codes

Effective July 1, 2020, CMS will discontinue the following procedure codes:

Discontinued Procedure Codes Direct Replacement Procedure Code
C9041 J7169
C9053 J0791
C9054 J0691
C9056 J0223
C9057 J1201
C9058 Q5120


Discontinued Procedure Codes with No Direct Replacement
C9754 C9755 J9199

Discontinued procedure codes will not be reimbursed after June 30, 2020.

Second Quarter 2020 HCPCS Revised Procedure Codes

Procedure Codes
C9758 J7321 J9245

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