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 27, 2019, TMHP implemented the second quarter 2019 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after July 1, 2019. The HCPCS updates are detailed in this article.
Second Quarter 2019 HCPCS Added Procedure Codes
Clinician Administered Drug (CAD) Procedure Codes | ||||||
---|---|---|---|---|---|---|
C9049 | C9050 | C9051 | C9052 | J7208 | J9030* | J9036 |
* = Rate hearing not required |
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, 2019. 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, 2019, 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
Effective July 1, 2019, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:
Non-CAD Procedure Codes | |||||
---|---|---|---|---|---|
90619 | C9756* | ||||
CAD Procedure Codes | |||||
C9047 | C9048 | J1444 | J7677 | J9356 | Q5112 |
Q5113 | Q5114 | Q5115 | |||
* = Texas Medicaid rate hearing required |
New benefits adopted by Texas Medicaid must complete the rate hearing process to receive public comment on proposed Texas Medicaid reimbursement rates.
After the rate hearing, expenditures must be approved before Texas Medicaid adopts the rates. Providers will be notified in a future banner message or notification if a proposed reimbursement rate will change or if a procedure code will not be reimbursed because the expenditures are not approved.
Restrictions for Procedure Code C9049
Procedure code C9049 will require prior authorization and will be restricted to clients who are two years of age and older.
In fee-for-service, the provider must submit requests for prior authorization for procedure code C9049 to TMHP using the Special Medical Prior Authorization (SMPA) Request Form.
Additional medical necessity criteria will be published in a future notification.
Prior Authorization for Procedure Code C9050
Procedure code C9050 will require prior authorization.
In fee-for-service, the provider must submit requests for prior authorization for procedure code C9050 to TMHP using the SMPA Request Form.
Additional medical necessity criteria will be published in a future notification.
Age Limitation for Procedure Code C9051
Procedure code C9051 will be a benefit for clients ages eight and older.
Restrictions for Procedure Code C9052
Procedure code C9052 will be a benefit for clients ages 18 and older, and will be restricted to diagnosis code D595.
Diagnosis Restriction for Procedure Code J9030
Procedure code J9030 will be restricted to the following diagnosis codes:
Diagnosis Codes | |||||
---|---|---|---|---|---|
C670 | C671 | C672 | C673 | C674 | C675 |
C676 | C677 | C678 | C679 | C7911 | D090 |
Second Quarter 2019 HCPCS Discontinued Procedure Codes
Effective July 1, 2019, CMS will discontinue the following procedure codes:
Procedure Codes | |||
---|---|---|---|
C9042* | C9141** | C9746*** | J9031**** |
* = Replaced by procedure code J9036 ** = Replaced by procedure code J7208 *** = Replaced by informational procedure code 0548T **** = Replaced by procedure code J9030 |
Discontinued procedure codes will not be reimbursed after June 30, 2019.
Second Quarter 2019 HCPCS Revised Procedure Code
The description of the following procedure code will be revised:
Procedure Code |
---|
J9355 |
Second Quarter 2019 HCPCS Informational Procedure Codes
The following procedure codes will be added as informational only:
Procedure Codes |
||
---|---|---|
0057U |
0084U |
0085U |
0086U |
0087U |
0088U |
0089U |
0090U |
0091U |
0092U |
0093U |
0094U |
0095U |
0096U |
0097U |
0098U |
0099U |
0100U |
0101U |
0102U |
0103U |
0104U |
0543T |
0544T |
0545T |
0546T |
0547T |
0548T |
0549T |
0550T |
0551T |
0552T |
0553T |
0554T |
0555T |
0556T |
0557T |
0558T |
0559T |
0560T |
0561T |
0562T |
For more information, call the TMHP Contact Center at 800-925-9126.