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Radiology Benefit Updates for Texas Medicaid Effective September 1, 2023

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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.

Certain radiology benefit updates will be effective for Texas Medicaid for dates of service on or after September 1, 2023.

Overview of Changes

Major changes include the following:

  • The addition of benefit information for magnetic resonance elastography (MRE)
  • New benefit for ultrasound transient elastography (TE)

MRE

MRE (procedure code 76391) may be reimbursed for the diagnosis or monitoring of liver fibrosis or cirrhosis in clients suspected of having, or who have been diagnosed with, chronic liver disease.

Prior authorization is required for outpatient nonemergent MRE. Refer to the current Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, subsection 3.2.6, “Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services,” for prior authorization guidelines that also apply to MRE.

Performance of MRE may be reimbursed up to two times per rolling year but may not be reimbursed within six months following a liver biopsy or TE, as it is not medically necessary.

TE

TE (procedure code 91200) may be reimbursed for the diagnosis or monitoring of liver fibrosis or cirrhosis in clients suspected of having, or who have been diagnosed with, chronic liver disease.

Procedure code 91200 will be a benefit as follows:

  • The total component when the service is rendered in the following settings:
    • The office setting by physician, portable X-ray supplier, radiological laboratory, and physiological laboratory providers
    • The outpatient hospital setting by hospital providers
  • The professional component when the service is rendered in the office, inpatient hospital, or outpatient hospital setting by physician providers.
  • The technical component when the service is rendered in the office setting by physician, portable X-ray supplier, radiological laboratory, and physiological laboratory providers.

Procedure code 91200 will be limited to the following diagnosis codes:

Diagnosis Codes

K710

K7110

K7111

K712

K713

K714

K7150

K7151

K716

K717

K718

K719

K7400

K7401

K7402

K742

K7581

K760

Performance of TE may be reimbursed up to two times per rolling year but may not be reimbursed within six months following a liver biopsy or MRE, as it is not medically necessary.

TE may be inappropriate and ineffective in clients with obesity, ascites, or narrow intercostal spaces.

Documentation Requirements

If a liver biopsy (procedure code 47000 or 47100) is performed within six months after TE or MRE, documentation of medical necessity must be maintained in the client's records and is subject to retrospective review.

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