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Updates for Monoclonal Antibody Therapy Administration Codes M0239 and M0243

Last updated on 1/25/2021

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 November 9, 2020, procedure code M0239 (administration of Bamlanivimab) can be billed by the following provider types in nursing home settings:

  • Physician (D.O.)
  • Physician (M.D.)
  • Physician Group (D.O.s only)
  • Clinic/Group Practice

Effective for dates of service on or after November 21, 2020, procedure code M0243 (administration of Casivirimab and Imdevimab) can be billed by the following provider types in nursing home settings:

  • Physician (D.O.)
  • Physician (M.D.)
  • Physician Group (D.O.s only)
  • Clinic/Group Practice

Procedure codes M0239 and M0243 are pending a rate approval hearing, and are not currently benefits. Services provided before the rate hearing is completed and expenditures are approved will be denied with the following 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.”

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

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