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Effective March 1, 2021, Medical Physics Consultations to Become Benefits of Texas Medicaid

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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.

Effective for dates of service on or after March 1, 2021, medical physics consultations (procedure codes 77336 and 77370) will become benefits of Texas Medicaid.

Medical physics consultations (procedure codes 77336 and 77370) will be a benefit of Texas Medicaid when services are performed by physician and radiation therapy center providers in the office setting, and radiation therapy center and hospital providers in the outpatient hospital setting.

Procedure codes 77336 and 77370 may be reimbursed to the ordering physician if consultation is performed with a qualified medical physicist for stereotactic radiosurgery, brachytherapy, or any other method of radiation therapy for which medical necessity is determined.

Prior Authorization

Procedure codes 77336 and 77370 will require prior authorization.

Refer to: The current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistant Handbook, subsection 9.2.60.2.1, “Prior Authorization for Stereotactic Radiosurgery,” for additional information about prior authorization requirements.

Limitations

Procedure code 77336 will be limited to once per week of treatment.

Procedure code 77370 will be limited to once per course of treatment. A special medical physics consultation may be reimbursed when the input and complex analysis of a qualified medical physicist are beyond that of a continuing medical physics consultation and are necessary to address a patient-specific reason or scenario.

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