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Additional Provider Types and Places of Service Added for Monoclonal Antibody Therapy Administration Codes M0240, M0241, M0243, and M0244

Last updated on 10/27/2021

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 September 9, 2021, monoclonal antibody therapy administration codes (procedure codes M0240, M0241, M0243, and M0244) will be payable to additional provider types and places of service.

This update is in response to the amended COVID-19 Public Readiness and Emergency Preparedness (PREP) Act declaration to allow pharmacists to order and administer selected COVID-19 therapeutics, including subcutaneous monoclonal antibodies (mAbs).

Pharmacists and pharmacies may now be reimbursed for procedure codes M0240, M0241, M0243, and M0244 rendered in the office, home, nursing home (skilled nursing facility/extended care facility), and intermediate care facility.

Procedure codes M0240 and M0243 are now payable for the following settings and provider types:

Place of Service

Provider Type

Office

Pharmacist, Pharmacy

Nursing Home (SNF/ICF)

Pharmacist

Nursing Home (ECF)

Pharmacist

Procedure codes M0241 and M0244 are now payable for the following setting and provider type:

Place of Service

Provider Type

Home

Pharmacist

Affected claims with dates of service on or after September 9, 2021 will be reprocessed, and providers may receive additional payment. Additional payments will be reflected on future Remittance and Status (R&S) Reports. Providers are not required to appeal the claims unless they are denied for additional reasons after the claims reprocessing is complete.

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