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Reminder: Use Appropriate Procedure Codes With Revenue Codes on Outpatient Hospital Claims

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This article has been updated. For more information, refer to Delayed Implementation of the Outpatient Prospective Payment System (OPPS) Reimbursement Methodology | TMHP.

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.

Outpatient hospital providers are reminded to use the most appropriate, valid Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) procedure code with revenue codes listed on an outpatient hospital claim, per guidance from the Texas Medicaid Provider Procedures Manual (TMPPM) and the National Uniform Billing Committee (NUBC).

Note: Revenue codes that are included on an outpatient hospital claim for informational purposes are exempt from the procedure code requirement.

Texas Medicaid is making changes to prepare for a new claim pricing structure, known as 3M™ Enhanced Ambulatory Patient Groups (EAPGs). Texas Medicaid will continue to reimburse hospital outpatient services using revenue codes until further notice. Outpatient hospital providers should get in the habit of coding outpatient hospital claims to include procedure codes in preparation for the transition to EAPG reimbursement. More information about this transition will be posted on tmhp.com when it becomes available.

Note that MCOs will not be required to adopt EAPG.

Email PFD_OPPS@hhs.texas.gov with any questions.