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New PENS Procedure Codes Effective July 1, 2024

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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.

Effective for dates of service on or after July 1, 2024, percutaneous electrical nerve stimulation (PENS) procedure codes 64596, 64597, and 64598 will be a benefit when services are provided in an inpatient or outpatient hospital setting by a physician provider.

Note: New benefits that are adopted by Texas Medicaid must be presented at a rate hearing 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 article if a proposed reimbursement rate will change or a procedure code will not be reimbursed because the expenditures are not approved.

Procedure codes 64596, 64597, and 64598 will require prior authorization beginning August 1, 2024.

Refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.45.11 “Percutaneous Electrical Nerve Stimulation (PENS),” for additional benefit information and prior authorization requirements that apply to all PENS services.

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