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 26, 2024, Texas Medicaid & Healthcare Partnership (TMHP) will implement the third quarter 2024 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2024. The HCPCS updates are detailed in this article.
Third Quarter 2024 HCPCS Added Procedure Codes
Clinician-Administered Drug (CAD) Procedure Codes | ||
---|---|---|
C9169 | C9170 | J0138 |
J1171 | J2252 | J2601 |
J8522 | J8541 | Q5135 |
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, 2024. 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, 2024, 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, 2024, the following procedure codes will be added as noncovered procedure codes for Texas Medicaid:
CAD Procedure Codes | ||
---|---|---|
C9171 | C9172 | J1749 |
J2002 | J2003 | J2004 |
J2253 | J9329 | Q5136 |
Non-CAD Procedure Codes | ||
---|---|---|
90624 | 90684* | A2027 |
A2028 | A2029 | A4543 |
A4544 | A4545 | A7021 |
A9610 | C8000 | E0469 |
E0683* | E0715 | E0716 |
E0721 | E0737 | E0743 |
E0767 | E2513 | E3200 |
L1006 | L1653* | L1821* |
L8720 | L8721 | P9027* |
Q0519 | Q0520 | Q4334 |
Q4335 | Q4336 | Q4337 |
Q4338 | Q4339 | Q4340 |
Q4341 | Q4342 | Q4343 |
Q4344 | Q4345 |
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.
The following procedure codes will be added as benefits for Healthy Texas Women and the state-funded Family Planning Program:
Procedure Codes | ||
---|---|---|
90684 | J0138 | J2252 |
J2601 |
Additional Benefit Information
Age limitations will apply for the following procedure codes:
Procedure Codes | Client Age Limitation |
---|---|
L1653, L1821 | Birth through 20 years of age |
Q5135 | Two years of age or older |
C9169, C9170, J2601, J8541 | 18 years of age or older |
90684 | 19 years of age or older |
Procedure codes L1653 and L1821 will require prior authorization. Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.19.2, “Prior Authorization and Documentation Requirements,” for additional information.
Procedure code Q5135 will be restricted to the following diagnosis codes:
Diagnosis Codes | ||||||
---|---|---|---|---|---|---|
M0500 | M05011 | M05012 | M05019 | M05021 | M05022 | M05029 |
M05031 | M05032 | M05039 | M05041 | M05042 | M05049 | M05050 |
M05052 | M05059 | M05061 | M05062 | M05069 | M05071 | M05072 |
M05079 | M0509 | M0510 | M05111 | M05112 | M05119 | M05121 |
M05122 | M05129 | M05131 | M05132 | M05139 | M05141 | M05142 |
M05149 | M05151 | M05152 | M05159 | M05161 | M05162 | M05169 |
M05171 | M05172 | M05179 | M0519 | M0520 | M05211 | M05212 |
M05219 | M05221 | M05222 | M05229 | M05231 | M05232 | M05239 |
M05241 | M05242 | M05249 | M05251 | M05252 | M05259 | M05261 |
M05262 | M05269 | M05271 | M05272 | M05279 | M0259 | M0530 |
M05311 | M05312 | M05319 | M05321 | M05322 | M05329 | M05331 |
M05332 | M05339 | M05341 | M05342 | M05349 | M05351 | M05352 |
M05359 | M05361 | M05362 | M05369 | M05371 | M05372 | M05379 |
M0539 | M0540 | M05411 | M05412 | M05419 | M05421 | M05422 |
M05429 | M05431 | M05432 | M05439 | M05441 | M05442 | M05449 |
M05451 | M05452 | M05459 | M05461 | M05462 | M05469 | M05471 |
M05472 | M05479 | M0549 | M0550 | M05511 | M05512 | M05519 |
M05521 | M05522 | M05529 | M05531 | M05532 | M05539 | M05541 |
M05542 | M05549 | M05551 | M05552 | M05559 | M05561 | M05562 |
M05569 | M05571 | M05572 | M05579 | M0559 | M0560 | M05611 |
M05612 | M05619 | M05621 | M05622 | M05629 | M05631 | M05632 |
M05639 | M05641 | M05642 | M05649 | M05651 | M05652 | M05659 |
M05661 | M05662 | M05669 | M05671 | M05672 | M05679 | M0569 |
M0570 | M05711 | M05712 | M05719 | M05721 | M05722 | M05729 |
M05731 | M05732 | M05739 | M05741 | M05742 | M05749 | M05751 |
M05752 | M05759 | M05761 | M05762 | M05769 | M05771 | M05772 |
M05779 | M0579 | M057A | M0580 | M05811 | M05812 | M05819 |
M05821 | M05822 | M05829 | M05831 | M05832 | M05839 | M05841 |
M05842 | M05849 | M05851 | M05852 | M05859 | M05861 | M05862 |
M05869 | M05871 | M05872 | M05879 | M0589 | M058A | M059 |
M0600 | M06011 | M06012 | M06019 | M06021 | M06022 | M06029 |
M06031 | M06032 | M06039 | M06041 | M06042 | M06049 | M06051 |
M06052 | M06059 | M06061 | M06062 | M06069 | M06071 | M06072 |
M06079 | M0609 | M060A | M0680 | M06811 | M06812 | M06819 |
M06821 | M06822 | M06829 | M06831 | M06832 | M06839 | M06841 |
M06842 | M06849 | M06851 | M06852 | M06859 | M06861 | M06862 |
M06869 | M06871 | M06872 | M06879 | M0689 | M068A | M069 |
M0820 | M08211 | M08212 | M08219 | M08221 | M08222 | M08229 |
M08231 | M08232 | M08239 | M08241 | M08242 | M08249 | M08251 |
M08252 | M08259 | M08261 | M08262 | M08269 | M08271 | M08272 |
M08279 | M0829 | M082A | M083 | M315 | M316 |
Third Quarter 2024 HCPCS Discontinued Procedure Codes
Effective October 1, 2024, CMS will discontinue the following procedure codes:
Discontinued Procedure Code | Direct Replacement Procedure Code |
---|---|
C9150 | A9610 |
Discontinued Procedure Codes With No Direct Replacement | ||
---|---|---|
0078U | 0167U | 0396U |
J1170 | J2001 | J8520 |
J8521 | J9258 |
Discontinued procedure codes will not be reimbursed after September 30, 2024.
Third Quarter 2024 HCPCS Revised Procedure Codes
The description of the following procedure codes will be revised:
Procedure Codes | ||
---|---|---|
0248U | 0403U | 0472U |
A2024 | A4271 | E0739 |
J2251 | J9172 | L1652 |
L1820 | Q0516 | Q0517 |
Q0518 |
Note: Procedure code 0472U will be effective for dates of service on or after July 1, 2024, and procedure codes Q0516, Q0517, and Q0518 will be effective for dates of service on or after September 15, 2024.
Third Quarter 2024 HCPCS Informational Procedure Codes
The following procedure codes will be added as informational only:
Procedure Codes | ||
---|---|---|
0476U | 0477U | 0478U |
0479U | 0480U | 0481U |
0482U | 0483U | 0484U |
0485U | 0486U | 0487U |
0488U | 0489U | 0490U |
0491U | 0492U | 0493U |
0494U | 0495U | 0496U |
0497U | 0498U | 0499U |
0500U | 0501U | 0502U |
0503U | 0504U | 0505U |
0506U | 0507U | 0508U |
0509U | 0510U | 0511U |
0512U | 0513U | 0514U |
0515U | 0516U | 0517U |
0518U | 0519U | 0520U |
For more information, call the TMHP Contact Center at 800-925-9126.