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Third Quarter 2021 HCPCS Updates for Texas Medicaid

Last updated on 10/15/2021

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 September 21, 2021, TMHP implemented the third quarter 2021 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which were effective for dates of service on or after October 1, 2021.

Third Quarter 2021 HCPCS Added Procedure Codes

Clinician Administered Drug (CAD) Procedure Codes

C9081

C9082

C9083

C9084

J0699

J0741

J1305

J1426

J1448

J7294

J7295

J9247

J9318

J9319

Q2054

Procedure codes J0699, J7294, and J7295 are also benefits for the Healthy Texas Women (HTW) and HTW Plus Programs and the Family Planning Program.

Reminder: The clinician administered drug procedure codes listed in the table above were added as Medicaid benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, October 1, 2021. Claims will be denied 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 October 1, 2021, 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 refer to the following website for details related to rate hearings: https://pfd.hhs.texas.gov/rate-packets.

Effective October 1, 2021, the following procedure codes were added as non-covered procedure codes for Texas Medicaid:

CAD Procedure Codes

J1445

J2406

 

Non-CAD Procedure Codes

A4453

C1831

C9779

C9780

K1021

K1022*

K1023

K1024

K1025

K1026

K1027

P9025*

P9026*

Q4251

Q4252

Q4253

Q9004

S9432

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

Limitations

Age limitations apply for the following procedure codes:

Procedure Codes

Client Age Limitations

C9081, C9082, C9083, C9084, J0699, J0741, J1448, J9247, Q2054

18 years of age or older

J1305

12 years of age or older

Procedure code K1022 is limited to clients from birth through 20 years of age and requires prior authorization.

Prior Authorization Requirements

Procedure code J1426 is a replacement for discontinued procedure code C9075 and will have the same prior authorization requirements.

Note: 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.

Coronavirus (COVID-19) Related Procedure Codes

The following COVID-19 related procedure codes are benefits of Texas Medicaid for clients who are 12 years of age or older:

Procedure Codes

Effective Dates

M0244, M0246

May 6, 2021

M0240, M0241

July 30, 2021

M0248

May 26, 2021

Procedure codes M0240, M0241, M0244, and M0246 are limited to diagnosis codes U071 and Z20822.

Procedure code M0248 is limited to diagnosis code U071.

The following procedure codes were added as informational only:

Procedure Codes

Effective Dates

M0249, M0250, Q0249

June 24, 2021

Q0240

July 30, 2021

The descriptions of procedure codes 0003A and 0013A were revised.

Third Quarter 2021 HCPCS Discontinued Procedure Codes

Effective October 1, 2021, CMS discontinued the following procedure codes:

Discontinued Procedure Codes

Direct Replacement Procedure Codes

C9075

J1426

C9077

J0741

C9078

J1448

C9079

J1305

Discontinued Procedure Codes With No Direct Replacement

0139U

0168U

C9065

C9076

C9080

J0693

J7303

J9315

Q4228

Q4236

   

Discontinued procedure codes will not be reimbursed after September 30, 2021.

Third Quarter 2021 HCPCS Revised Procedure Codes

The descriptions of the following procedure codes were revised:

Procedure Codes

J1443

J2407

K1013

Third Quarter 2021 HCPCS Informational Procedure Codes

The following procedure codes were added as informational only:

Procedure Codes

0018M

0255U

0256U

0257U

0258U

0259U

0260U

0261U

0262U

0263U

0264U

0265U

0266U

0267U

0268U

0269U

0270U

0271U

0272U

0273U

0274U

0275U

0276U

0277U

0278U

0279U

0280U

0281U

0282U

0283U

0284U

   

The description of procedure code 0051U was revised.

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