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Reimbursement Updates for Certain Renal Dialysis Drugs Effective January 1, 2025

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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 January 1, 2025, reimbursement for certain renal dialysis drugs will be updated.

Difelikefalin and Daprodustat

Difelikefalin (procedure code J0879) and daprodustat (procedure code J0889) will be benefits for clients who are 18 years of age or older when provided as follows:

Place of ServiceProvider Types
OfficePhysician assistant, nurse practitioner, clinical nurse specialist, physician, and nephrology (hemodialysis, renal dialysis) providers
Outpatient hospitalHospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and rural emergency hospital providers

Procedure codes J0879 and J0889 will be excluded from the composite rate and may be reimbursed separately.

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.

Diagnosis Restrictions

Procedure code J0879 will be restricted to the following diagnosis codes:

Diagnosis Codes
L2989N170N171N172N178N179N181
N182N1830N1831N1832N184N185N186
N189N990T795XXAT795XXDT795XXS  

Procedure code J0889 will be restricted to the following diagnosis codes:

Diagnosis Codes
D631N170N171N172N178N179N181
N182N1830N1831N1832N184N185N186
N189N990T795XXAT795XXDT795XXS  

Epoetin Alfa-epbx (Ratacrit)

Epoetin Alfa-epbx (Ratacrit) (procedure code Q5105) will be excluded from the composite rate and may be reimbursed separately.

Diagnosis Restrictions

Procedure code Q5105 will be restricted to the following diagnosis codes:

Diagnosis Codes
D631N170N171N172N178N179N181
N182N1830N1831N1832N184N185N186
N189N990T795XXAT795XXDT795XXS  

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