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 |
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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 |
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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.