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First Quarter 2023 HCPCS Updates for Texas Medicaid

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On March 30, 2023, TMHP implemented the first quarter 2023 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after April 1, 2023. The HCPCS updates are detailed in this article.

First Quarter 2023 HCPCS Added Procedure Codes

Clinician-Administered Drug (CAD) Procedure Codes

C9146

C9147

C9148

J0208

J0218

J0612

J0613

J1449

J1747

J9196

J9294

J9296

J9297

Q5128

Procedure codes J0612 and J0613 will be included in the composite rate payment and will not be paid separately for renal dialysis facilities.

Reminder: The CAD procedure codes listed in the table above will be added as Medicaid benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, April 1, 2023. Claims will deny 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 April 1, 2023, published rate until the HHSC rate hearing is held, as required by the Texas Administrative Code 355.201.

Providers may also refer to the following website for details related to rate hearings: https://pfd.hhs.texas.gov/rate-packets

Effective April 1, 2023, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:

CAD Procedure Codes

C9145

C9149

J1411

J2403

Q5127

Q5129

Q5130

Non-CAD Procedure Codes

A2019

A2020

A2021

A4341

A4342

A4560*

A6590

A6591

A7049

E0677

E0711

E1905

K1035

L8678*

Q4265

Q4266

Q4267

Q4268

Q4269

Q4270

Q4271

S9563

Procedure codes noted with an asterisk in the table above will require a Texas Medicaid rate hearing.

New benefits that are adopted by Texas Medicaid must complete the rate hearing process to receive public comment on proposed Texas Medicaid reimbursement rates.

After the rate hearing, expenditures must be approved before the rates are adopted by Texas Medicaid. Providers will be notified in a future notification if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures are not approved.

Limitations

Procedure codes C9146, C9147, and C9148 will be limited to clients who are 18 years of age or older.

Procedure code J0218 will be restricted to diagnosis codes E75241 and E75244.

Procedure code J1449, which is a granulocyte colony stimulating factor, will be restricted by diagnosis and limited to clients who are 18 years of age or older.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.25, “Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim),” for a list of payable diagnosis codes for colony stimulating factors.

Procedure code J1747 will be restricted to diagnosis code L401 and limited to clients who are 18 years of age or older.

Procedure code L8678 will be a benefit for clients with a purchased device and a claims history of a prior neurostimulator or neuromuscular stimulator implantation within the past five years.

Refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.44.16, “Supplies for Neurostimulators,” for additional requirements.

First Quarter 2023 HCPCS Discontinued Procedure Codes

Effective April 1, 2023, CMS will discontinue the following procedure codes:

Discontinued Procedure Codes

Direct Replacement Procedure Codes

J0610

J0612

J0611

J0613

Discontinued Procedure Codes with No Direct Replacement

0324U

0325U

C1834

Discontinued procedure codes will not be reimbursed after March 31, 2023.

First Quarter 2023 HCPCS Revised Procedure Codes

The description of the following procedure codes will be revised:

Procedure Codes

A4628

J1954

K1019

M1209

Q5108

Q5111

Q5120

Q5122

S9562

First Quarter 2023 HCPCS Informational Procedure Codes

The following procedure codes will be added as informational only:

Procedure Codes

0364U

0365U

0366U

0367U

0368U

0369U

0370U

0371U

0372U

0373U

0374U

0375U

0376U

0377U

0378U

0379U

0380U

0381U

0382U

0383U

0384U

0385U

0386U

M0010

The descriptions of procedure codes 0022U and 0095U will be revised.

First Quarter 2023 HCPCS Modifier Updates

Modifier

Action

JK

ADD

JL

ADD

LU

REVISE DESCRIPTION

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