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Third Quarter 2026 HCPCS Updates for Texas Medicaid

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On September 30, 2026, the Texas Medicaid & Healthcare Partnership (TMHP) will implement the third quarter 2026 Healthcare Common Procedure Coding System (HCPCS) additions, revisions, and discontinuations, which will be effective for dates of service on or after October 1, 2026. This article details the HCPCS updates.

Third Quarter 2026 HCPCS Added Procedure Codes

Clinician-Administered Drug (CAD) Procedure Codes
C9311C9313J0643J0644J0871J1757J1818J1946J1947J1957
J1958J3268J3406J7524J7526J7529J7530J7531J9186J9187
J9191J9192J9362Q5172      

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, 2026. 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, 2026, 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
87638A4228E0788L1972L8697     

Note: Procedure code 87638 will be effective for dates of service on or after May 15, 2026. Providers can refer to the Rate and Code Updates – Required CLIA Lab Certifications page on tmhp.com for the required laboratory certifications for procedure code 87638.

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
J7531         

Effective October 1, 2026, Texas Medicaid will add the following procedure codes as noncovered procedure codes:

CAD Procedure Codes
C9312J9066Q5173       
Non-CAD Procedure Codes
A2046A2047A2048A2049A2050A6614A9613E2403G0685J0014
L1330Q4207Q4223Q4243      

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

Procedure Codes
A2046A2047A2048A2049A2050A9613Q4207Q4223Q4243 

Additional Benefit Information

Age limitations will apply for the following procedure codes:

Procedure CodesClient Age Limitation
C9311, C9313, J1946, J3268, J9186, J936218 years of age or older
J18182 years of age or older
J19476 years of age or older
J340612 years of age or older
L1972Birth through 20 years of age

Procedure code J3406 will require prior authorization and replaces procedure code J3590 when submitting claims for omidubicel-onlv (Omisirge). Refer to the current TMPPM, Outpatient Drug Services Handbook, subsection 6.96.1, “Prior Authorization Requirements,” for additional information.

Procedure code L1972 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.

Procedure code A4228 will require prior authorization. Refer to the current Texas Medicaid Provider Procedures Manual (TMPPM), Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsections 2.2.16.1, “Prior Authorization,” and 2.2.16.2 “Documentation Requirements,” for additional information.

The following procedure codes will be diagnosis-restricted:

Procedure CodesDiagnosis Restrictions
C9311E851
C9313C864
E0788G20A1, G20A2, G20B1, G20B2, G20C
J1757E761
J1818E7221
J1946, J1947I501, I5020, I5022, I5023, I5030, I5032, I5033, I5040, I5042, I5043, I50810, I50812, I50813, I50814, I5082, I5083, I5084, I5089, I509

Procedure codes J7524, J7526, J7529, and J7530 may be indicated for, but are not limited to, treatment for prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants.

Third Quarter 2026 HCPCS Discontinued Procedure Codes

Effective October 1, 2026, CMS will discontinue the following procedure codes:

Procedure Codes
0556U0557U0585UC8010C9046C9310C9462J0640J1941J1953
J7514J7517J7519J7528J9181J9190J9352L8696  

Claims for discontinued procedure codes will not be reimbursed after September 30, 2026.

Third Quarter 2026 HCPCS Revised Procedure Codes

CMS will revise the descriptions of the following procedure codes:

Procedure Codes
A9595C1982C8004C9797J3300J9033L1971L8030L8031L8035
S0169         

Third Quarter 2026 HCPCS Informational Procedure Codes

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

Procedure Codes
0660U0661U0662U0663U0664U0665U0666U0667U0668U0669U
0670U0671U0672U0673U0674U0675U0676U0677U0678U0679U
0680U0681U0682U0683U0684U0685U0686U0687U0688U0689U
0690U0691U0692U0693U0694U0695U0696U0697U0698U1054T
1055T1056T1057T1058T1059T1060T1061T1062T1063T1064T
1065T1066T1067T1068T1069T1070T1071T1072T1073T1074T
1075T1076T1077T1078T1079T1080T1081T1082T1083T1084T
1085T1086T1087T1088T1089T1090T1091T1092T1093T1094T
1095T1096T1097T1098T1099T1100T1101T1102T1103T1104T
1105T1106T1107T1108T1109T1110T1111T   

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

Procedure Codes
0247U0591U0600U0601U0602U0603U0604U0605U0606U0607U
0608U0609U0610U0611U0612U0613U0614U0615U0616U0617U
0618U0619U0620U0621U0622U0623U0624U0625U0626U0627U
0628U0629U0630U0631U0632U0633U0634U0635U0636U0637U
0638U0639U0640U0641U0642U0643U0644U0645U0646U0647U
0648U0649U0650U0651U0652U0653U0654U0655U0656U0657U
0658U0659U0894T0895T0896T     

Updates for Procedure Codes From a Previous Quarter

Texas Medicaid will add the following procedure codes as benefits, pending a required rate hearing:

CAD Procedure Codes
J1749J3424J7176Q5161Q5168Q5169    

Texas Medicaid will add the following procedure codes as informational only, effective for dates of service on or after July 1, 2026:

Procedure Codes
M0231M0232Q0234       

Additional Benefit Information

Age limitations will apply for the following procedure codes:

Procedure CodesClient Age Limitation
J1749, J3424, Q516818 years of age or older
Q516112 years of age or older

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.