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 |
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J1445 |
J2406 |
Non-CAD Procedure Codes |
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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.