Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.
On July 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will implement the second quarter 2025 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after July 1, 2025. The HCPCS updates are detailed in this article.
Second Quarter 2025 HCPCS Added Procedure Codes
Clinician-Administered Drug (CAD) Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
C9174 | C9175 | J0165 | J0168 | J0616 | J0618 | J1163 | J1326 | J2312 | J2313 |
J3373 | J3374 | J3375 | J3391 | J7172 | J7356 | J9220 | J9276 | J9289 | J9342 |
J9382 | Q2058 | Q5099 | Q5100 |
Reminder: The CAD 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, 2025. 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, 2025, published rate until the Texas Health and Human Services Commission (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: https://pfd.hhs.texas.gov/rate-packets
The Healthy Texas Women (HTW) Program will add the following procedure codes as HTW Plus benefits:
CAD Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
J2312 | J2313 |
Effective July 1, 2025, the following procedure codes will be added as noncovered procedure codes for Texas Medicaid:
CAD Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
J0166 | J0167 | J0169 | J9174 | J9275 | J9341 | Q5098 | Q5153 |
Non-CAD Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
90382 | 90612 | 90613 | 90635 | 91323 | Q4368 | Q4369 | Q4370 | Q4371 | Q4372 |
Q4373 | Q4375 | Q4376 | Q4377 | Q4378 | Q4379 | Q4380 | Q4382 |
Additional Benefit Information
Age limitations will apply for the following procedure codes:
Procedure Codes | Client Age Limitation |
---|---|
C9174, J1326, J7356, J9276, J9289, J9382, Q2058 | 18 years of age or older |
C9175 | 1 year of age or older |
J3391 | Birth through 18 years of age |
J7172 | 12 years of age or older |
Q5099, Q5100 | 6 years of age or older |
Procedure code J1326 will be restricted to the following diagnosis codes:
Diagnosis Codes | |||||||
---|---|---|---|---|---|---|---|
C155 | C158 | C159 | C160 | C161 | C162 | C163 | C164 |
C165 | C166 | C168 | C169 |
Procedure code J9276 will be restricted to diagnosis codes C221, C23, C240, C248, and C249.
Procedure codes Q5099 and Q5100 will be restricted to the following diagnosis codes:
Diagnosis Codes | |||||||
---|---|---|---|---|---|---|---|
K5000 | K50011 | K50012 | K50013 | K50014 | K50018 | K50019 | K5010 |
K50111 | K50112 | K50113 | K50114 | K50118 | K50119 | K5080 | K50811 |
K50812 | K50813 | K50814 | K50818 | K50819 | K5090 | K50911 | K50912 |
K50913 | K50914 | K50918 | K50919 | K5100 | K51011 | K51012 | K51013 |
K51014 | K51018 | K51019 | K5120 | K51211 | K51212 | K51213 | K51214 |
K51218 | K51219 | K5130 | K51311 | K51312 | K51313 | K51314 | K51318 |
K51319 | K5180 | K51811 | K51812 | K51813 | K51814 | K51818 | K51819 |
K5190 | K51911 | K51912 | K51913 | K51914 | K51918 | K51919 | L400 |
L401 | L402 | L403 | L404 | L4050 | L4051 | L4052 | L4053 |
L4054 | L4059 | L408 | L409 |
The following injections, when used for the treatment of end-stage renal disease or acute kidney injury, will be included in the composite rate payment and will not be paid separately:
- Metoprolol tartrate (procedure code J0616)
- Calcium chloride (procedure code J0618)
- Vancomycin hydrochloride (procedure code J3373)
Second Quarter 2025 HCPCS Discontinued Procedure Codes
Effective July 1, 2025, CMS will discontinue the following procedure codes:
Discontinued Procedure Codes | Direct Replacement Procedure Codes |
---|---|
C9300 | J9220 |
C9301 | Q2058 |
C9302 | J9276 |
C9304 | J7172 |
Discontinued Procedure Codes with No Direct Replacement | |||||||||
---|---|---|---|---|---|---|---|---|---|
C9173 | C9303 | G9037 | G9038 | J0171 | J0173 | J2310 | J2311 | J3370 | J3371 |
J3372 | J9340 |
Discontinued procedure codes will not be reimbursed after June 30, 2025.
CMS will discontinue procedure code M0248 effective December 12, 2024.
Second Quarter 2025 HCPCS Revised Procedure Codes
The description of the following procedure codes will be revised:
Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
77435 | 90620 | 99406 | C8005 | J1954 | J9292 | Q9998 |
Note: Procedure code C8005 will be effective for dates of service on or after April 1, 2025.
Second Quarter 2025 HCPCS Informational Procedure Codes
The following procedure codes will be added as informational only:
Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
0552U | 0553U | 0554U | 0555U | 0556U | 0557U | 0558U | 0559U | 0560U | 0561U |
0562U | 0563U | 0564U | 0565U | 0566U | 0567U | 0568U | 0569U | 0570U | 0571U |
0572U | 0573U | 0574U | 0948T | 0949T | 0950T | 0951T | 0952T | 0953T | 0954T |
0955T | 0956T | 0957T | 0958T | 0959T | 0960T | 0961T | 0962T | 0963T | 0964T |
0965T | 0966T | 0967T | 0968T | 0969T | 0970T | 0971T | 0972T | 0973T | 0974T |
0975T | 0976T | 0977T | 0978T | 0979T | 0980T | 0981T | 0982T | 0983T | 0984T |
0985T | 0986T | 0987T |
CMS will revise the descriptions of the following informational procedure codes:
Procedure Codes | |||||||||
---|---|---|---|---|---|---|---|---|---|
0285U | 0521U | 0522U | 0523U | 0524U | 0525U | 0526U | 0527U | 0528U | 0529U |
0530U | 0531U | 0532U | 0533U | 0534U | 0535U | 0536U | 0537U | 0538U | 0539U |
0540U | 0541U | 0542U | 0543U | 0544U | 0545U | 0546U | 0547U | 0548U | 0549U |
0550U | 0551U |
For more information, call the TMHP Contact Center at 800-925-9126.