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Additional Diagnosis Code for Monoclonal Antibody Therapy Administration Codes M0245 and M0246

Last updated on 11/1/2021

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.

The U.S. Food and Drug Administration has revised the emergency use authorization (EUA) for Eli Lilly brand monoclonal antibody therapy (bamlanivimab and etesevimab, administered together) to include emergency use as postexposure prophylaxis (prevention) for COVID-19 in adults and pediatric patients (12 years of age or older weighing at least 40 kg) who are at high risk for progression to severe COVID-19, including hospitalization or death.

Effective for dates of service on or after September 16, 2021, diagnosis code Z20822, indicating possible exposure to COVID-19, will be added as a payable diagnosis for procedure codes M0245 and M0246 for monoclonal antibody therapy administration.

Affected claims with dates of service submitted from September 16, 2021, through September 23, 2021, will be reprocessed. Providers may receive an additional payment, which will be reflected on future Remittance and Status Reports.

For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.