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 September 1, 2022, vaccine services benefits will change for Texas Medicaid.
The following procedure code will become a benefit for vaccine services:
Procedure Code |
Age Range |
Number of Recognized Components |
---|---|---|
90759 |
18 years and older |
1 |
The following procedure codes will no longer be a benefit for vaccine services because of the discontinuation of the associated vaccine or inappropriate utilization:
Procedure Codes |
|||||
---|---|---|---|---|---|
90644 |
90650 |
90733 |
90748 |
90749 |
Texas Vaccines for Children (TVFC) Providers
Procedure code 90461 may not be billed by Texas Vaccines for Children (TVFC) providers when administering TVFC-eligible vaccines under the TVFC program.
Nephrology and Renal Dialysis Facility Providers
The following procedure codes will be benefits for nephrology providers in the office setting and nephrology providers and renal dialysis facilities in the outpatient hospital setting:
Procedure Codes |
Category |
---|---|
90371, J1571, J1573 |
Hepatitis B immune globulin |
90740, 90747 |
Hepatitis B vaccine for immunocompromised/dialysis patients |
90630, 90654, 90655, 90656, 90657, 90658, 90661, 90662, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90756 |
Influenza vaccine |
90670, 90671, 90677, 90732 |
Pneumococcal vaccine |
90460, 90471, 90472 |
Vaccine administration |
Federally Qualified Health Center (FQHC) Providers
Federally qualified health center (FQHC) providers will no longer be reimbursed for services rendered in the home setting for the following procedure codes:
Procedure Codes |
|||||
---|---|---|---|---|---|
90460 |
90461 |
90471 |
90472 |
90473 |
90474 |
90620 |
90621 |
90630 |
90632 |
90633 |
90636 |
90647 |
90648 |
90651 |
90654 |
90655 |
90656 |
90657 |
90658 |
90660 |
90661 |
90662 |
90670 |
90672 |
90680 |
90681 |
90685 |
90686 |
90687 |
90688 |
90696 |
90698 |
90700 |
90702 |
90707 |
90710 |
90713 |
90714 |
90715 |
90716 |
90723 |
90732 |
90734 |
90736 |
90740 |
90743 |
90744 |
90746 |
90747 |
90750 |
90756 |
Covered Age Ranges for Vaccines and Vaccine Administration
The age range limitations will be updated for the following procedure codes:
Procedure Code |
Age Range |
90473 |
All ages |
90474 |
All ages |
90620 |
10 years or older |
90621 |
10 years or older |
90630 |
6 months or older |
90632 |
18 years or older |
90633 |
Birth through 18 years |
90636 |
19 years or older |
90647 |
6 weeks through 18 years |
90648 |
6 weeks or older |
90651 |
9 years through 45 years |
90654 |
6 months or older |
90660 |
6 months through 20 years |
90661 |
6 months or older |
90662 |
65 years or older |
90670 |
2 months or older |
90672 |
2 years through 49 years |
90673 |
6 months or older |
90674 |
6 months or older |
90680 |
Birth through 8 months |
90681 |
Birth through 8 months |
90698 |
Birth through 5 years |
90707 |
1 year or older |
90710 |
1 year through 12 years |
90713 |
2 months or older |
90716 |
1 year or older |
90723 |
6 weeks through 6 years |
90732 |
2 years or older |
90734 |
2 months through 55 years |
90740 |
20 years or older |
90743 |
11 years through 17 years |
90744 |
Birth through 17 years |
90746 |
18 years or older |
90747 |
20 years or older |
Influenza
The following places of service and provider types will no longer be reimbursed for procedure codes 90673 and 90682:
Place of Service |
Provider Type |
---|---|
Office |
Comprehensive Health Center (CHC), Family Planning Clinic |
Home |
Certified Nurse Midwife, Registered Nurse, Licensed Midwife |
Outpatient Hospital |
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Birthing Center, CHC |
Other Locations |
Certified Nurse Midwife, Registered Nurse, Licensed Midwife, CHC, Family Planning Clinic |
Meningococcal Vaccine
Procedure code 90734 may now be reimbursed to comprehensive care providers (CCP) for services rendered in the office, home, and other settings.
Bacille Calmette-Guerin (BCG) Vaccine
The following places of service and provider types may now be reimbursed for procedure code 90585:
Place of Service |
Provider Type |
---|---|
Office |
Certified Nurse Midwife, Registered Nurse, Licensed Midwife, Comprehensive Care Program (CCP) |
Home |
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, CCP |
Other Locations |
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Physician Group, CCP |
Procedure code 90585 must be billed with diagnosis code Z201 and will be limited to one service per day, same procedure, any provider.
Hepatitis B Immune Globulin
Procedure codes 90371, J1571, and J1573 must be billed with diagnosis code Z205. Procedure codes J1571 and J1573 will no longer be reimbursed for dentist and dentistry group providers for services rendered in the office setting and for durable medical equipment (DME) medical suppliers for services rendered in the home setting.
Rabies Post-Exposure Prophylaxis
The following places of services and provider types will no longer be reimbursed for procedure codes 90375 and 90376:
Place of Service |
Provider Type |
---|---|
Office |
Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
Home |
Rural Health Clinic – Freestanding/Independent |
Outpatient Hospital |
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Physician, Clinic/Group Practice, Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
Other Locations |
Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
The following places of services and provider types will no longer be reimbursed for procedure code 90675:
Place of Service |
Provider Type |
---|---|
Office |
Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
Home |
Rural Health Clinic – Freestanding/Independent |
Outpatient Hospital |
Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
Other Locations |
Rural Health Clinic – Freestanding/Independent and Rural Health Clinic – Hospital Based |
For more information, call the TMHP Contact Center at 800-925-9126.