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 September 28, 2023, the Texas Medicaid & Healthcare Partnership (TMHP) implemented the third quarter 2023 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2023. The HCPCS updates are detailed in this article.
Third Quarter 2023 HCPCS Added Procedure Codes
|Clinician-Administered Drug (CAD) Procedure Codes|
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, October 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 October 1, 2023, published rate until the Texas Health and Human Services (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 October 1, 2023, the following procedure codes will be added as non-covered procedure codes for Texas Medicaid:
|CAD Procedure Codes|
|Non-CAD Procedure Codes|
Additional Benefit Information
Medication-assisted treatment procedure code C9154 may be separately reimbursed from withdrawal management and treatment services in the outpatient or residential setting.
The following procedure codes will be restricted to clients who are 18 years of age or older:
Tofersen (procedure code C9157) will be restricted to diagnosis code G1221 and limited to clients who are 18 years of age or older.
Mycophenolate mofetil (procedure code J7519) may be indicated for but is not limited to treatment for prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants.
Third Quarter 2023 HCPCS Discontinued Procedure Codes
Effective October 1, 2023, CMS will discontinue the following procedure codes:
Discontinued procedure codes will not be reimbursed after September 30, 2023.
Third Quarter 2023 HCPCS Revised Procedure Codes
The description of the following procedure codes will be revised:
Note: Procedure code 91304 will be effective for dates of service on or after August 14, 2023.
Third Quarter 2023 HCPCS Informational Procedure Codes
The following procedure codes will be added as informational only:
The description of the following informational procedure codes will be revised:
For more information, call the TMHP Contact Center at 800-925-9126.