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|
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: www.hhs.texas.gov/about-hhs/communications-events/meetings-events
The following procedure codes will be added as non-covered procedure codes for Texas Medicaid:
|CAD Procedure Codes|
|Non-CAD Procedure Codes|
Procedure codes noted with an asterisk in the table above will require a Texas Medicaid rate hearing.
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|
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:
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|
|Discontinued Procedure Codes with No Direct Replacement|
Discontinued procedure codes will not be reimbursed after June 30, 2020.
Second Quarter 2020 HCPCS Revised Procedure Codes
For more information, call the TMHP Contact Center at 800-925-9126.