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LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT® ")

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Third Quarter 2025 HCPCS Updates for Texas Medicaid

Last updated on 10/1/2025

On October 1, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) will implement the third quarter 2025 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2025. This article details the HCPCS updates.

Third Quarter 2025 HCPCS Added Procedure Codes

Clinician-Administered Drug (CAD) Procedure Codes
C9305	C9306	J0163	J0164	J0458	J0525	J0582	J0614	J0668	J0738
J0752	J0759	J1370	J1807	J1809	J1834	J2151	J2291	J3290	J3402
J3403	J7173	J7174	J9011

Note: Procedure code J3290 is a Medicaid-only benefit and is not covered by Medicare.

Texas Medicaid will add the CAD procedure codes listed in the table above as benefits as of the Centers for Medicare & Medicaid Services (CMS) effective date, October 1, 2025. TMHP will deny claims until a rate is implemented, but affected claims will be reprocessed back to the CMS effective date. Procedure codes will be reimbursable at the rate that is effective on October 1, 2025, until the Texas Health and Human Services Commission (HHSC) conducts a rate hearing, as required by Texas Administrative Code §355.201.

Providers may refer to the HHSC Provider Finance website for details related to rate hearings.

Non-CAD Procedure Codes
A4288	E0658	E0659	J0570	L1007	L6034

Texas Medicaid will add the non-CAD procedure codes listed in the table above as benefits pending a required rate hearing.

All new benefits must go through the Texas Medicaid rate hearing process to allow for public comment on proposed reimbursement rates.

After the rate hearing, Texas Medicaid must approve the expenditures before the rates can be adopted. TMHP will notify providers in a future article if a proposed reimbursement rate will change or if claims for a procedure code will not be reimbursed because the expenditures are not approved.

The Healthy Texas Women (HTW) Program will add the following procedure code as a benefit:

Procedure Code for HTW Plus Only
J0570

Effective October 1, 2025, Texas Medicaid will add the following procedure codes as noncovered procedure codes:

CAD Procedure Codes
A9612	J0462	J0675	J0681	J1612	Q5154	Q5155	Q5156	Q5157	Q5158
Q5159

Non-CAD Procedure Codes
A2036	A2037	A2038	A2039	A9616	C1740	C1741	C1742	E0150	L5657
L6035	L6036	L6038	L6039	Q4383	Q4384	Q4385	Q4386	Q4387	Q4388
Q4389	Q4390	Q4391	Q4392	Q4393	Q4394	Q4395	Q4396	Q4397

The following procedure codes are not benefits because they are considered part of another service:

Procedure Codes
A2036	A2037	A2038	A2039	A9612	A9616	C1741	Q4383	Q4384	Q4385
Q4386	Q4387	Q4388	Q4389	Q4390	Q4391	Q4392	Q4393	Q4394	Q4395
Q4396	Q4397

Additional Benefit Information

Age limitations will apply for the following procedure codes:

Procedure Codes	Client Age Limitation
C9305, J7173, J7174	12 years of age or older
C9306, E0658, E0659, J0164, J0458, J0668, J3403, J9011	18 years of age or older
J0570, J0738, J0752	16 years of age or older
J0614	One year of age or older
J3402	Two months of age or older
L1007, L6034	Birth through 20 years of age

Procedure code A4288 must be submitted with modifier U8 within 12 months of the purchase of a breast pump and will be limited to a maximum of two replacements.

Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook, subsections 3.2, “Replacement Parts,” and 3.6.1, “Replacement Parts,” for additional information about requirements for breast pump replacement parts.

Procedure code C9305 will be restricted to diagnosis codes G7000 and G7001.

Procedure codes E0658 and E0659 will be restricted to diagnosis codes I890, I898, I972, and Q820.

Medication-assisted treatment procedure code J0570 may be separately reimbursed from withdrawal management and treatment services in the outpatient or residential setting. The ordering physician, physician assistant, or advanced practice registered nurse must be separately enrolled as a Texas Medicaid provider even when the billing provider is a chemical-dependency treatment facility or opioid treatment provider.

Procedure code J0614 will require prior authorization. Refer to the current TMPPM, Outpatient Drug Services Handbook, subsection 6.133.1, “Prior Authorization Requirements,” for additional information.

Mannitol (procedure code J2151), when used for the treatment of end-stage renal disease or acute kidney injury, will be included in the composite rate payment, and claims will not be reimbursed separately.

Procedure code L1007 will require prior authorization. Refer to the current TMPPM, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.19.2, “Prior Authorization and Documentation Requirements,” for additional information. Only one procedure code, either L1007 or L0634, may be reimbursed on the same day by the same provider.

Procedure code L6034 will require prior authorization. Refer to the current TMPPM, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.20.2, “Prior Authorization and Documentation Requirements,” for additional information.

Third Quarter 2025 HCPCS Discontinued Procedure Codes

Effective October 1, 2025, CMS will discontinue the following procedure codes:

Discontinued Procedure Codes	Direct Replacement Procedure Codes
C9088	J0668
C9174	J9011
C9175	J0614
J2150	J2151

Discontinued Procedure Codes With No Direct Replacement
0450U	0451U	C9248	J2503	S0074

Claims for discontinued procedure codes will not be reimbursed after September 30, 2025.

Third Quarter 2025 HCPCS Revised Procedure Codes

CMS will revise the descriptions of the following procedure codes:

Procedure Codes
90612	90613	90635	91323	C1739	C1982	E0765	E0986	J1961	J7300
J9072	J9333	L5673	L5679	L5783	L6028	L7406

Note: The revised description for procedure code J1961 will be effective for dates of service on or after June 18, 2025.

Third Quarter 2025 HCPCS Informational Procedure Codes

Texas Medicaid will add the following procedure codes as informational only:

Procedure Codes
0575U	0576U	0577U	0578U	0579U	0580U	0581U	0582U	0583U	0584U
0585U	0586U	0587U	0588U	0589U	0590U	0591U	0592U	0593U	0594U
0595U	0596U	0597U	0598U	0599U	C8006	M0235	M0236	M0237	M0238
Q0235	Q0237

Note: Procedure codes M0237, M0238, and Q0237 will be effective for dates of service on or after January 24, 2025.

CMS will revise the descriptions of the following informational procedure codes:

Procedure Codes
0285U	0552U	0553U	0554U	0555U	0556U	0557U	0558U	0559U	0560U
0561U	0562U	0563U	0564U	0565U	0566U	0567U	0568U	0569U	0570U
0571U	0572U	0573U	0574U

Updates for Procedure Codes From a Previous Quarter

Effective for dates of service on or after October 1, 2025, Texas Medicaid will add the following procedure codes as benefits, pending a required rate hearing:

CAD Procedure Codes
J0166	J0167	J0169	J7601	J9341	Q5136	Q5151	Q5152

Non-CAD Procedure Codes
C9807	C9808	J0901

Age limitations will apply for the following procedure codes:

Procedure Codes	Client Age Limitation
J0901, J7601	18 years of age or older

Procedure code J0901 will be restricted to diagnosis codes D631 and N186.

Procedure codes Q5151 and Q5152 will be restricted to diagnosis codes D5932, D5939, D595, G7000, and G7001.

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

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.

Third Quarter 2025 HCPCS Updates for Texas Medicaid

Third Quarter 2025 HCPCS Added Procedure Codes

Additional Benefit Information

Third Quarter 2025 HCPCS Informational Procedure Codes

Updates for Procedure Codes From a Previous Quarter

Texas Medicaid Virtual Assistant