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First Quarter 2021 HCPCS Updates for Texas Medicaid

Last updated on 3/29/2021

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.

On March 30, 2021, TMHP will implement the first quarter 2021 Healthcare Common Procedure Coding System additions, revisions, and discontinuations, which will be effective for dates of service on or after April 1, 2021.

First Quarter 2021 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes

J1427*

J1554*

J7402

J9037*

J9349*

Q2053*

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, April 1, 2021. 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 April 1, 2021, 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: https://rad.hhs.texas.gov/rate-packets

Effective April 1, 2021, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

CAD Procedure Codes

C9074

   

Non-CAD Procedure Codes

A9592

C9776*

C9777

K1013*

K1014

K1015

K1016

K1017

K1018

K1019

K1020

S1091*

Procedure codes noted with an asterisk in the table above will require a Texas Medicaid rate hearing.

Age Limitations

The following procedure codes will be a benefit for clients who are 18 years of age and older:

Procedure Codes

J7402

J9037

J9349

Q2053

S1091

 

Prior Authorization Requirements

Procedure code J1427 is a replacement for discontinued procedure code C9071 and will have the same prior authorization requirements.

Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.7, “Antisense Oligonucleotides (eteplirsen, golodirsen, and nusinersen),” for the prior authorization requirements.

Procedure code Q2053 is a replacement for discontinued procedure code C9073, and will have the same prior authorization requirements.

Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.16, “Chimeric Antigen Receptor (CAR) T-Cell Therapy,” for the prior authorization requirements.

First Quarter 2021 HCPCS Discontinued Procedure Codes

Effective April 1, 2021, CMS will discontinue the following procedure codes:

Discontinued Procedure Codes

Direct Replacement Procedure Codes

C9068

A9592

C9069

J9037

C9070

J9349

C9071

J1427

C9072

J1554

C9073

Q2053

C9122

J7402

Discontinued Procedure Codes with No Direct Replacement

0098U

0099U

0100U

J7333

J7401

K1010

K1011

K1012

 

Discontinued procedure codes will not be reimbursed after April 1, 2021.

First Quarter 2021 HCPCS Revised Procedure Codes

The description of the following procedure codes will be revised:

Procedure Codes

81529

C9761

D1110

D1120

G2140

G9868

G9869

G9870

J7321

First Quarter 2021 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

Procedure Codes

0017M

0242U

0243U

0244U

0245U

0246U

0247U

G2020

G2172

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