Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 March 1, 2022, renal dialysis benefits will change for Texas Medicaid.
The following list summarizes the changes to the benefit language:
- Acute renal failure will be updated to acute kidney injury (AKI).
- Method I or Method II will be updated to consolidated billing.
Composite Rate Payments
One of the following revenue codes must be billed for the dialysis facility to receive the composite rate payment for maintenance services or to receive the composite rate payment for clients being treated in the home setting.
Revenue Code |
Limitations |
821 |
3 per week |
831 |
3 per week |
841 |
Hemodialysis (HD) – equivalent sessions |
851 |
HD – equivalent sessions |
Consolidated Billing
The following laboratory procedure codes will be subject to end-stage renal disease (ESRD) consolidated billing:
Procedure Codes |
|||||
---|---|---|---|---|---|
80047^ |
80048^ |
80051^ |
80053^ |
80069^ |
80076 |
82040^ |
82108 |
82306 |
82310^ |
82330^ |
82374^ |
82379 |
82435^ |
82565^ |
82570^ |
82575 |
82607 |
82610 |
82652 |
82668 |
82728 |
82746 |
83540 |
83550 |
83735 |
83970 |
84075^ |
84100 |
84132^ |
84134 |
84155^ |
84157 |
84295^ |
84466 |
84520^ |
84540 |
84545 |
85014^ |
85018^ |
85025^ |
85027 |
85041 |
85044 |
85045 |
85046 |
85048 |
86704 |
86705 |
86706 |
87040 |
87070 |
87071 |
87073 |
87075 |
87076 |
87077 |
87081 |
87340 |
87341 |
G0306 |
G0307 |
G0499 |
|||
QW^ Modifier |
All drugs and biologicals used for the treatment of ESRD or AKI (unless specified otherwise) are included in the composite rate payment and are not paid separately. This includes the following procedure codes:
Procedure Codes |
|||||
---|---|---|---|---|---|
A4216 |
A4217 |
A4802 |
J0360 |
J0604 |
J0606 |
J0610 |
J0620 |
J0630 |
J0636 |
J0670 |
J0878 |
J0884 |
J0887 |
J0895 |
J0945 |
J1160 |
J1200 |
J1205 |
J1240 |
J1265 |
J1270 |
J1443 |
J1444 |
J1445 |
J1642 |
J1644 |
J1720 |
J1740 |
J1750 |
J1800 |
J1940 |
J1945 |
J1955 |
J2001 |
J2150 |
J2360 |
J2430 |
J2501 |
J2720 |
J2795 |
J2993 |
J2997 |
J2365 |
J3364 |
J3365 |
J3370 |
J3410 |
J3420 |
J3480 |
J3489 |
J7030 |
J7040 |
J7402 |
J7050 |
J7060 |
J7070 |
J7120 |
J7131 |
Q0613 |
Q5105 |
The following drug procedure codes that are used for the treatment of ESRD are excluded from the composite rate and will be paid separately:
Procedure Codes |
|||||
---|---|---|---|---|---|
J0882 |
J1439 |
J1756 |
J2916 |
Q0139 |
Q4081 |
Maintenance Hemodialysis
ESRD facilities that furnish dialysis treatments in-facility are paid up to 3 treatments per week. ESRD facilities that treat patients in the home setting, regardless of modality, receive payment for three hemodialysis equivalent treatments per week.
Maintenance Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD)
For clients undergoing CAPD or CCPD in the home setting, the number of days of peritoneal dialysis, regardless of dialysate exchanges performed each day, is converted to hemodialysis-equivalent sessions. This is accomplished by dividing the number of days of peritoneal dialysis by 7 and multiplying the result by 3.
Revenue Code Updates
Revenue codes 845 and 855 will no longer be reimbursed for renal dialysis services.
The following revenue codes will no longer be reimbursed to the provider type at the listed places of service:
Revenue Code |
Provider Type |
Place of Service |
---|---|---|
634, 635, 636 |
Renal Dialysis Facility |
Inpatient Hospital |
636 |
Nephrology (Hemodialysis, Renal Dialysis) |
Outpatient Hospital, Other Locations |
The following provider types and places of service will no longer be reimbursed for revenue code 880:
Provider Type |
Place of Service |
---|---|
Psychiatric Hospital, Renal Dialysis Facility, Rural Health Clinic – Hospital Based |
Inpatient Hospital |
Psychiatric Hospital, Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility, Rural Health Clinic – Freestanding/Independent and Hospital Based |
Outpatient Hospital |
All Provider Types |
Other Locations |
The following diagnosis codes will be added and may be reimbursed for revenue codes 821, 829, 831, 839, 841, 849, and 851:
Diagnosis Codes |
|||||
---|---|---|---|---|---|
N1830 |
N1831 |
N1832 |
N990 |
T795XXA |
T795XXD |
T795XXS |
Revenue codes 829, 839, 849, and 859 will be limited to one per day, any procedure, any provider.
Revenue codes 841 and 851 will be limited to three chronic renal disease (CRD) maintenance intermittent peritoneal dialysis (IPD) sessions per calendar week, any provider.
The following diagnosis codes will be added and may be reimbursed for revenue code 859:
Diagnosis Codes |
|||||
---|---|---|---|---|---|
N170 |
N171 |
N172 |
N178 |
N179 |
N181 |
N182 |
N1830 |
N1831 |
N1832 |
N184 |
N185 |
N186 |
N189 |
N990 |
T795XXA |
T795XXD |
T795XXS |
Diagnosis codes N185 and N186 will be added and may be reimbursed for revenue code 880.
Procedure Codes
The following procedure codes will no longer be restricted by diagnosis:
Procedure Codes |
|||||
36000 |
49421 |
78351 |
82040 |
82310 |
82374 |
82435 |
82565 |
83550 |
84075 |
84100 |
84132 |
84155 |
84520 |
85014 |
85018 |
85025 |
85041 |
93005 |
A4770 |
E1530 |
E1610 |
E1615 |
E1625 |
J0630 |
The following procedure codes will be denied when billed with procedure code G0257 and revenue code 880:
Procedure Codes |
|||||
---|---|---|---|---|---|
36000 |
36430 |
36591 |
36593 |
49421 |
93041 |
A4216 |
A4217 |
A4651 |
A4652 |
A4657 |
A4660 |
A4663 |
A4670 |
A4680 |
A4690 |
A4706 |
A4707 |
A4708 |
A4709 |
A4714 |
A4719 |
A4720 |
A4721 |
A4722 |
A4723 |
A4724 |
A4725 |
A4726 |
A4730 |
A4736 |
A4737 |
A4740 |
A4750 |
A4755 |
A4760 |
A4765 |
A4766 |
A4772 |
A4773 |
A4774 |
A4802 |
A4860 |
A4911 |
A4913 |
A4918 |
A4927 |
A4928 |
A4929 |
A4930 |
A4931 |
A4932 |
E0424 |
E0431 |
E0434 |
E0439 |
E1510 |
E1520 |
E1530 |
E1540 |
E1550 |
E1560 |
E1570 |
E1575 |
E1580 |
E1590 |
E1592 |
E1594 |
E1600 |
E1620 |
E1630 |
E1632 |
E1635 |
E1637 |
E1639 |
E1699 |
J0630 |
J1160 |
J1200 |
J1265 |
J1642 |
J1644 |
J1720 |
J1800 |
J1955 |
J2150 |
J2720 |
The following procedure codes will be denied when billed with procedure code G0257 and revenue codes 821, 829, 831, 839, 841, 849, 851, 859, and 880:
Procedure Codes |
|||||
71045 |
71046 |
71047 |
71048 |
78300 |
78305 |
78306 |
80047 |
80048 |
80051 |
80053 |
80069 |
80076 |
81020 |
81050 |
82040 |
82108 |
82306 |
82310 |
82330 |
82374 |
82379 |
82435 |
82565 |
82570 |
82575 |
82607 |
82610 |
82652 |
82668 |
82728 |
82746 |
82947 |
83540 |
83550 |
83615 |
83735 |
83970 |
84075 |
84100 |
84132 |
84134 |
84155 |
84156 |
84157 |
84160 |
84295 |
84450 |
84466 |
84520 |
84540 |
84545 |
85004 |
85007 |
85008 |
85014 |
85018 |
85025 |
85027 |
85041 |
85044 |
85045 |
85046 |
85048 |
85345 |
85347 |
85610 |
86704 |
86705 |
86706 |
87040 |
87070 |
87071 |
87075 |
87076 |
87077 |
87081 |
87340 |
87341 |
87073 |
93000 |
93005 |
93040 |
95907 |
95908 |
95909 |
95910 |
95911 |
95912 |
95913 |
A4215 |
A4244 |
A4245 |
A4246 |
A4247 |
A4248 |
A4450 |
A4452 |
A6204 |
A6215 |
A6216 |
A6250 |
A6260 |
A6402 |
G0306 |
G0307 |
G0499 |
J0610 |
J0636 |
J0670 |
J0878 |
J0844 |
J0887 |
J0895 |
J1205 |
J1240 |
J1270 |
J1740 |
J1750 |
J1940 |
J2360 |
J2430 |
J2501 |
J2795 |
J2797 |
J3370 |
J3410 |
J3420 |
J3480 |
J3489 |
J7030 |
J7040 |
J7402 |
J7050 |
J7060 |
J7070 |
J7120 |
Q0163 |
Q5105 |
The following procedure codes will no longer be reimbursed to the specified provider types at the listed places of service:
Procedure Codes |
Provider Type |
Place of Service |
---|---|---|
71045, 71046 |
Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility |
Office, Nursing Home (Skilled Nursing Facility/Intermediate Care Facility), Outpatient Hospital, Nursing Home (Extended Care Facility) |
78300, 78305, 78306 |
Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility |
Office, Inpatient Hospital, Outpatient Hospital, Independent Laboratory |
81050 |
Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility |
Office |
80069 |
Nephrology (Hemodialysis, Renal Dialysis), Renal Dialysis Facility |
Outpatient Hospital |
Procedure codes 71047, 95907, 95908, 95909, 95910, 95911, 95912, 95913, and 99001 will no longer be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers for services rendered in the office and outpatient hospital setting.
The following diagnosis codes will be added and may be reimbursed for procedure codes 90935, 90937, 90945, and 90947:
Diagnosis Codes |
|||||
---|---|---|---|---|---|
T795XXA |
T795XXD |
T795XXS |
The following diagnosis codes will be added and may be reimbursed for procedure codes 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, and 90970:
Diagnosis Codes |
|||||
---|---|---|---|---|---|
N990 |
T795XXA |
T795XXD |
T795XXS |
Procedure code 90966 will no longer be reimbursed to certified nurse midwife, registered nurse, and licensed midwife providers for services rendered in the inpatient hospital setting.
Procedure code E1575 will no longer be reimbursed to custom durable medical equipment (DME) providers for services rendered in any setting.
Procedure code E1530 will no longer be reimbursed to custom DME providers for services rendered in the home setting.
Procedure code E1635 will no longer be reimbursed to custom DME providers for services rendered in the office and home setting.
Procedure code G0257 will be limited to once per week, same procedure, any provider. Procedure code G0527 will be denied if not submitted with revenue code 880, same day, same claim, same provider.
For more information, call the TMHP Contact Center at 800-925-9126.