hcpcs special bulletin - tmhpjanuary 2014 no. 6 2014 healthcare common procedure coding system...

January 2014 no. 6

2014 Healthcare Common Procedure Coding System (HCPCS) Special BulletinHCPCS Special BulletinHCPCS Special Bulletin

2014 HCPCS ImplementationOn January 1, 2014, the Texas Medicaid & Healthcare Partnership (TMHP) applied the 2014 annual Healthcare Common Procedure Coding System (HCPCS) updates that are effective for dates of service on or after January 1, 2014.

This combined Special Bulletin includes the HCPCS updates for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. This bulletin is intended to notify providers of program and coding changes related to the 2014 updates for HCPCS and Current Procedural Terminology® (CPT).

All providers are encouraged to review the “General Information” section of this bulletin. Policy updates for a specific program or provider type are discussed in designated sections of the bulletin.

Note: This article applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization, and reimbursement.

Rate Hearings and Expenditure ReviewNew and increased benefits that are adopted by Texas Medicaid must complete the rate hearing process in order to receive comments on new and increased Texas Medicaid reimbursement rates. The CSHCN Services Program reviews the adopted Texas Medicaid rates to determine whether the rates are fiscally feasible for the CSHCN Services Program.

All new, revised, and discontinued 2014 HCPCS procedure codes are effective for dates of service on or after January 1, 2014. The new procedure codes that are designated with asterisks (*) in the “Texas Medicaid Allowable” and the

“CSHCN Services Program Allowable” columns of the table located on page 20 of this bulletin must complete the rate hearing process, and expenditures must be approved before the rates are adopted by Texas Medicaid and the CSHCN Services Program. Providers will be notified in a future banner message or web article if a new procedure code will not be reimbursed because the expenditures were not approved.

Providers may refer to the following resources for more information about the public rate hearings and approval of expenditures:

• Title 2 Human Resources Code, §32.0282, and Title 1 Texas Administrative Code (TAC), §355.201, which require public hearings

• House Bill 1, 80th Legislature, Regular Session, 2007, Article II, Department of State Health Services, Rider 79a

Copyright AcknowledgmentsUse of the American Medical Association’s (AMA) copyrighted CPT® is allowed in this publication with the following disclosure:

“Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regula tion System/ Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes:

“Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2012 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.”

InSIDE

All Providers 1

2014 HCPCS Implementation ............................................................................................................1Rate Hearings and Expenditure Review ............................................................................................1Claims Filing ...................................................................................................................................... 3Code Updates Web Page .................................................................................................................. 3

Medicaid Fee-for-Service and Managed Care Providers 3

Texas Medicaid HCPCS Updates ...................................................................................................... 3

Home Health and Comprehensive Care Program (CCP) Providers 10

Home Health Services Benefit Changes ........................................................................................ 10CCP Services Benefit Changes ...................................................................................................... 10

School Health and Related Services (SHARS) Providers 12

SHARS Benefit Changes .................................................................................................................12

THSteps Providers 13

THSteps Dental Benefit Changes .....................................................................................................13

DSHS Family Planning Providers 14

DSHS Family Planning Services Benefit Changes ..........................................................................14

Texas Women’s Health Program (TWHP) Providers 14

TWHP Providers Benefit Changes ...................................................................................................14

Children With Special Health Care Needs (CSHCN) Services Program Providers 15

CSHCN Services Program Updates ................................................................................................15CSHCN Services Program Benefit Changes ...................................................................................15

All Code Changes: Added, Revised, Replacement, and Discontinued 20

2014 HCPCS Procedure Code Additions ........................................................................................ 20Discontinued Procedure Codes ...................................................................................................... 33Replacement Procedure Codes ...................................................................................................... 33Procedure Code Description Changes ........................................................................................... 34Modifiers ...........................................................................................................................................37

Prior Authorization Changes 37

Authorization or Prior Authorization .................................................................................................37

Texas Medicaid Special Bulletin, No. 6 2 2014 HCPCS Special BulletinCPT only copyright 2013 American Medical Association. All rights reserved.

Claims FilingThe new 2014 HCPCS procedure codes may be billed beginning January 1, 2014, and must be submitted within the initial 95-day filing deadline. Services provided before the rate hearing is completed and expenditures are approved will be denied with an explanation of benefits (EOB) 02008, “This procedure code has been approved as a benefit pending the approval of expenditures. Providers will be notified of the effective dates of service in a future notification if expenditures are approved.”

Note: In the rare instance that expenditures are not approved for a particular procedure code, that procedure code will not be made a benefit effective January 1, 2014.

Once expenditures are approved, TMHP will automatically reprocess the affected claims. Providers are not required to appeal the claims unless they are denied for other reasons after the claims reprocessing is complete. When the affected claims are reprocessed, providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports.

If the effective date of service changes for one or more of the new procedure codes, providers will be notified in a future article. The client cannot be billed for these services.

Important: To avoid fraudulent billing, providers must submit the procedure codes that are most appropriate for the services provided.

Code Updates Web PageProviders are encouraged to refer to the TMHP Code Updates – HCPCS web page at www.tmhp.com/Pages/CodeUpdates/HCPCS_2014.aspx for reimbursement rates, quarterly HCPCS updates, and all other notifications about HCPCS procedure codes.

Medicaid Fee-For-Service and Managed care ProviderS

Texas Medicaid HCPCS UpdatesThe 2014 Healthcare Common Procedure Coding System (HCPCS) updates, including prior authorization updates for Texas Medicaid, are included in the HCPCS tables in the “All Code Changes” section of this bulletin beginning on page 20. The 2014 HCPCS deletions and replacements are effective January 1, 2014, for dates of service on or after January 1, 2014, for Texas Medicaid. Providers may refer to the “General Information” section for more information.

Authorization and Prior Authorization Update ReminderEffective January 1, 2014, the 2014 HCPCS deleted procedure codes are no longer reimbursed by Texas Medicaid. Unless otherwise indicated on page 33 of this bulletin, providers who have received prior authorization for dates of service that occur on, after, or encompass January 1, 2014, must submit a written request on the appropriate, completed Texas Medicaid prior authorization request form in order to update the HCPCS procedure codes autho-rized for those services.

Providers may refer to the section titled “Services That Require Authorization or Prior Authorization” on page 37 of this bulletin, for information about obtaining authorization or prior authorization.

Texas Medicaid Special Bulletin, No. 6 3 2014 HCPCS Special Bulletin

All Providers

CPT only copyright 2013 American Medical Association. All rights reserved.

http://www.tmhp.com

http://www.tmhp.com

Texas Medicaid Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2014 HCPCS and Current Proce-dural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more infor-mation, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.

Note: These changes apply to Texas Medicaid fee-for-service and Medicaid managed care claims and authorization requests that are submitted to TMHP for processing.

The policy articles in this bulletin contain the following information:

• Revised: The description has been revised for these procedure codes. Providers may refer to the appropriate copyright holder for the revised descriptions.

• Discontinued: Discontinued procedure codes are no longer reimbursed after December 31, 2013.

• Added: Added procedure codes are new procedure codes added by the Centers for Medicare & Medicaid Services (CMS). Procedure codes noted with an asterisk (*) require a rate hearing for pricing.

• Limitations: Additional benefit and limitation information for the added procedure codes.

• Replacement: Replacement procedure codes directly replace the indicated discontinued procedure code. The discontinued procedure codes are no longer reimbursed after December 31, 2013, and the replacement procedure codes are effective for dates of service on or after January 1, 2014. Not all discontinued procedure codes have direct replacements.

Blood Factor Productsadded Procedure CodeC9133

Limitations for added procedure code: Procedure code C9133 may be reimbursed as follows:

• To physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), and physician providers for services rendered in the office setting

• To hospital providers for services rendered in the outpatient hospital setting

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physi-cians, and Physician Assistants Handbook, subsection 9.2.39.7, “Antihemophilic Factor” for additional information.

Colony Stimulating Factorsadded Procedure CodeJ1442Discontinued Procedure CodesJ1440 J1441

Limitations for added procedure code: Procedure code J1442 may be reimbursed as follows:

• To PA, NP, CNS, and physician providers for services rendered in the office setting


Procedure code J2505 will not be reimbursed when submitted with the same date of service as procedure code J1442.


Medicaid Fee-For-Service and Managed Care Providers


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.11, “Colony Stimulating Factors (Filgrastim, Pegfil-grastim, and Sargramostim)” for additional information, including diagnosis restrictions.

Diagnostic Endoscopiesadded Procedure CodesC9735 43191 43192 43193 43197 43198 43253

Limitations for added procedure codes: The surgical component for these services may be reimbursed as follows:

• To PA, NP, CNS, and physician providers for services rendered in the office, inpatient, or outpatient hospital settings

• To ambulatory surgical center (ASC) providers for services rendered in the outpatient hospital setting

Doctor of Dentistry Services as a Limited PhysicianDiscontinued Procedure Codes13150 42802

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Special-ists, Physicians, and Physician Assistants Handbook, subsection 9.3.2.3, “Additional Payable Procedure Codes” for additional information.

Genetic Testing for Colorectal CancerDiscontinued Procedure CodesS3833 S3834

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.17.3, “Genetic Testing for Colorectal Cancer,” and subsection 9.2.17.3.1, “Testing for Familial Adenomatous Polyposis” for additional information.

Gynecological and Reproductive Health Servicesadded Procedure Codes87661 J7301

Limitations for added procedure codes: Procedure code 87661 may be reimbursed for all clients as follows:

• To PA, certified nurse midwife (CNM), CNS, NP, physician, federally qualified health center (FQHC), and family planning clinic providers for services rendered in the office setting

• To hospital providers in the outpatient hospital setting

• To independent laboratory providers in the inpatient laboratory setting

If any combination of procedure codes 87480, 87510, 87660, 87661, and 87800 are billed on the same date of service by the same provider, all will be denied.




Procedure code J7301 replaces discontinued procedure code Q0090 and may be reimbursed for female clients who are 10 through 55 years of age as follows:

• To PA, CNM, CNS, NP, physician, FQHC, and family planning clinic providers for services rendered in the office setting


Procedure code 58300 may be reimbursed if billed with procedure code J7300, J7301, or J7302.

Note: Procedure codes 87661 and J7301 are not benefits of the Texas Women’s Health Program.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Gynecological and Reproductive Health and Family Planning Services Handbook,” subsection 2.2.2.1, “FQHC Reimbursement for Other Family Planning Office or Outpatient Visits,” subsection 2.2.5.2.1, “Insertion of the IUD,” subsection 5.5, “Assays for the Diagnosis of Vaginitis” and the Clinics and Other Outpatient Facility Services Handbook, subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” and subsection 4.4.1, “Claims Information” for additional information.

Immunosuppressive Drugsadded Procedure CodesJ0717 J1602

Limitations for added procedure codes: Procedure codes J0717 and J1602 may be reimbursed as follows:

• To PA, NP, CNS, and physician providers in the office setting


Procedure codes J0717 and J1602 must be submitted with an 11-digit National Drug Code (NDC) from the Texas Supplemental NDC File or the Noridian NDC/HCPCS crosswalk.

Note: The Noridian NDC/HCPCS crosswalk provides a listing of NDCs that are assigned to HCPCS procedure codes. The crosswalk is a valuable resource for providers, but it may not contain a complete listing of all NDCs for any given procedure code.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.16, “Immunosuppressive Drugs” for additional information.

Injections – Immune Globulinsadded Procedure CodeJ1556


• To PA, NP, CNS and physician providers in the office setting

• To medical supplier providers in the home setting


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.14, “Immune Globulin” for additional information.




Injections – Interferonadded Procedure CodesQ3027 Q3028Discontinued Procedure CodesQ3025 Q3026

Limitations for added procedure codes: Procedure codes Q3027 and Q3028 may be reimbursed as follows:

• To PA, NP, CNS, physician, and podiatrist providers in the office setting


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.17, “Interferon” for additional information.

Physical, Occupational, and Speech Therapy – Traditional Medicaidadded Procedure Codes92521 92522 92523 92524Discontinued Procedure Code92506

Limitations for added procedure codes: Procedure codes 92521, 92522, 92523, and 92524 may be reimbursed as follows:

• To PA, NP, CNS, School Health and Related Services (SHARS), physician, physical therapy (PT), and occupa-tional therapy (OT), and comprehensive care program (CCP) providers for services rendered in the office setting

• To SHARS, PT, OT, home health agency, and CCP providers for services rendered in the home setting

• To PA, NP, CNS, and physician providers for services rendered in the inpatient hospital setting

• To PA, NP, CNS, physician, home health agency, hospital, rehabilitation center, and rural health clinic (RHC) providers for services rendered in the outpatient hospital setting

• To PA, NP, CNS, SHARS, physician, PT, OT, home health agency, CCP, hospital, rehabilitation center, and RHC providers for services rendered in the “other location” setting

Speech therapy evaluation procedure code 92506 was discontinued and replaced by the more specific procedure codes 92521, 92522, 92523, and 92524.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsec-tion 2.4.5.1, “Services, Benefits, and Limitations,” subsection 2.11.3.2, “Services, Benefits, and Limitations,” subsec-tion 3.3.1, “Audiology,” subsection 3.3.1.1, “Audiology Billing Table,” subsection 3.3.9.2, “Description of Services,” subsection 3.3.9.4, “Speech Therapy Billing Table” and the Nursing and Therapy Services Handbook, subsection 4.2.3, “ST Services” for additional information.

Screening and Diagnostic Studies of the BreastDiscontinued Procedure Codes77031 77032




Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Special-ists, Physicians, and Physician Assistants Handbook, subsection 9.2.15.4, “Mammography (Screening and Diagnostic Studies of the Breast)” for additional information.

Skin TherapyDiscontinued Procedure Codes17003 17312 17314 17315

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.68, “Skin Therapy” for additional information.

Surgical – Otheradded Procedure Codes23333 23334 23335 37217 37236 37237 37238 37239 52356 6461664617

Limitations for added procedure codes: The added procedure codes listed in the above table may be reimbursed to physician providers in the office, and inpatient and outpatient hospital settings and must include an LT/RT modifier.

Vaccine and Toxoid Administrationadded Procedure Code90673

Limitations for added procedure code: Procedure code 90673 may be reimbursed as follows:

• To NP, CNS, PA, physician, pharmacist, CNM, CCP, comprehensive health center, family planning clinic, FQHC, and Texas Health Steps (THSteps) medical providers for services rendered in the office setting

• To NP, CNS, PA, physician, CNM, CCP, FQHC, and THSteps medical providers for services rendered in the home setting

• To NP, CNS, PA, physician, CNM, birthing center, comprehensive health center, hospital, FQHC, and THSteps medical providers for services rendered in the outpatient hospital setting

• To NP, CNS, PA, physician, CNM, CCP, comprehensive health center, family planning clinic, FQHC, and THSteps medical providers for services rendered in the “other location” setting

Procedure code 90673 is limited to clients who are 19 years of age and older, once per rolling year, any provider.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.35, “Immunization Guidelines and Administration” and the Children’s Services Handbook, subsection 5.3.11.3, “Immunizations” for additional information.

Vaccines and Toxoidsadded Procedure Code90673





• To NP, CNS, PA, physician, pharmacist, CNM, CCP, comprehensive health center, family planning clinic, FQHC, and THSteps medical providers for services rendered in the office setting

• To NP, CNS, PA, physician, CNM, CCP, FQHC, and THSteps medical providers for services rendered in the home setting

• To NP, CNS, PA, physician, CNM, birthing center, comprehensive health center, hospital, FQHC, and THSteps medical providers for services rendered in the outpatient hospital setting

• To NP, CNS, PA, physician, CNM, CCP, comprehensive health center, family planning clinic, FQHC, and THSteps medical providers for services rendered in the “other location” setting

Procedure code 90673 is limited to clients who are 19 years of age and older, once per rolling year, any provider.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.35, “Immunization Guidelines and Administration” and the Children’s Services Handbook, subsection 5.3.11.3, “Immunizations” for additional information.

Wound Care Management Servicesadded Procedure CodesQ4137 Q4138 Q4140 Q4142 Q4143 Q4146 Q4147 Q4148 Q4149

Limitations for added procedure codes: Procedure codes Q4137, Q4138, Q4140, Q4142, Q4143, Q4146, Q4147, Q4148, or Q4149 may be reimbursed as follows:

• To physician, dentist, and podiatrist providers for services rendered in the office setting


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.79.1, “First-Line Wound Care Therapy” for additional information.

ASC/HASC Code Additions

Additions for ambulatory surgical center/hospital ambulatory surgical center (ASC/HASC) facil-ities are listed with appropriate group payments in the 2014 Healthcare Common Procedure Coding System (HCPCS) procedure code additions table located on page 20 and replacement procedure codes table located on page 33 of this bulletin.

For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.




HoMe HealtH and coMPreHenSive care PrograM (ccP) ProviderS

Home Health Services Benefit ChangesThe following Texas Medicaid Home Health Services benefit changes have been made to support the 2014 Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.

Incontinence Supplies – Home Healthadded Procedure CodeT4544

Limitations for added procedure code: Procedure code T4544 may be reimbursed to durable medical equipment (DME) home health and DME medical supplier providers for services rendered in the home setting.

Services are limited to 240 per calendar month without prior authorization, same or different procedure, when billed by any provider.

Revised procedure code T4543 and added procedure code T4544 replace procedure code T4528 billed with modifier U1 for the 2XL or greater sized incontinence product. Providers must use procedure code T4543 or T4544 to bill for the 2XL or greater adult sized disposable incontinence product. Procedure code T4548 must no longer be billed with modifier U1.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.13.9, “Incontinence Procedure Codes with Limitations” for more information.

CCP Services Benefit ChangesThe following Texas Medicaid CCP benefit changes have been made to support the 2014 HCPCS and CPT updates and are effective for dates of service on or after January 1, 2014. For more information, call the TMHP Contact Center at 1-800-925-9126.

Incontinence Supplies - CCPadded Procedure CodeT4544

Limitations for added procedure code: Procedure code T4544 may be reimbursed to DME home health and DME medical supplier providers for services rendered in the home setting.

Services are limited to 240 per calendar month without prior authorization, same or different procedure, when billed by any provider.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsec-tion 2.5.9, “Incontinence Supplies” for more information.


Home Health and Comprehensive Care Program Providers


Orthoses – CCP

added Procedure CodesL0455 L0457 L0467 L0469 L0641 L0642 L0643 L0648 L0649 L0650 L0651 L1812 L1833 L1848 L3678 L3809 L3916 L3918 L3924 L3930 L4361 L4387 L4397Discontinued Procedure CodeL0430

Limitations for added procedure codes: The added procedure codes listed in the above table require prior autho-rization and may be reimbursed as follows:

• To orthotist and medical supplier providers for services rendered in the home setting


These added procedure codes are limited to clients who are birth through 20 years of age.

Physical, Occupational, and Speech Therapy – CCPadded Procedure Codes92521 92522 92523 92524Discontinued Procedure Code92506

Limitations for added procedure codes: Procedure codes 92521, 92522, 92523, or 92524 may be reimbursed as follows:

• To physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), School Health and Related Services (SHARS), physician, physical therapy (PT), occupational therapy (OT), and Comprehensive Care Program (CCP) providers for services rendered in the office setting

• To SHARS, PT, OT, home health agency, and CCP providers for services rendered in the home setting

• To PA, NP, CNS, and physician providers for services rendered in the inpatient hospital setting

• To PA, NP, CNS, physician, home health agency, hospital, rehabilitation center, and rural health clinic (RHC) providers for services rendered in the outpatient hospital setting

• To PA, NP, CNS, SHARS, physician, PT, OT, home health agency, CCP, hospital, rehabilitation center, and RHC providers for services rendered in the “other location” setting


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsection 2.4.5.1, “Services, Benefits, and Limitations,” subsection 2.11.3.2, “Services, Benefits, and Limitations,” subsection 3.3.1, “Audiology,” subsection 3.3.1.1, “Audiology Billing Table,” subsection 3.3.9.2, “Description of Services,” subsection 3.3.9.4, “Speech Therapy Billing Table,” and the Nursing and Therapy Services Handbook, subsection 4.2.3, “ST Services” for more information.


Home Health and Comprehensive Care Program Providers


ScHool HealtH and related ServiceS (SHarS) ProviderS

SHARS Benefit ChangesThe following School Health and Related Services (SHARS) benefit changes have been made to support the 2014 Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.

Physical, Occupational, and Speech Therapy – Traditional Medicaidadded Procedure Codes92521 92522 92523 92524Discontinued Procedure Code92506

Limitations for added procedure codes: Procedure codes 92521, 92522, 92523, and 92524 may be reimbursed to SHARS providers for services rendered in the office, home, and “other location” settings.


Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsec-tion 3.3.1, “Audiology,” subsection 3.3.1.1, “Audiology Billing Table,” subsection 3.3.9.2, “Description of Services,” subsection 3.3.9.4, “Speech Therapy Billing Table,” and the Vision and Hearing Handbook, subsection 2.2.6.6,

“SHARS Audiology Services” for additional information.


School Health and Related Services Providers


tHStePS ProviderS

THSteps Dental Benefit ChangesThe following Texas Health Steps (THSteps) dental services benefit changes have been made to support the 2014 Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.

THSteps Diagnostic Dental ServicesDiscontinued Procedure CodeD0363

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsec-tion 4.2.13, “Diagnostic Services,” and subsection 4.2.32.1, “Cone Beam Imaging” for more information.

THSteps Therapeutic Dental Servicesadded Procedure CodesD5863 D5864 D5865 D5866Discontinued Procedure CodesD3354 D5860 D5861

Limitations for added procedure codes: Procedure codes D5863, D5864, D5865, and D5866 may be reimbursed to clients who are 4 through 20 years of age to FQHC, orthodontist, oral maxillofacial surgeon, and dental providers in the office, inpatient, and outpatient hospital settings.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization,” subsection 4.2.16, “Restorative Services,” subsection 4.2.17, “Endodontics Services,” subsection 4.2.19, “Prosthodontic (Removable) Services,” and subsection 4.2.32, “Mandatory Prior Authorization” for more information.


Texas Health Steps Providers


dSHS FaMily Planning ProviderS

DSHS Family Planning Services Benefit ChangesThe following Department of State Health Services (DSHS) family planning benefit changes have been made to support the 2014 Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126.

Gynecological and Reproductive Health Servicesadded Procedure Codes87661 J7301

Limitations for added procedure codes: Procedure code 87661 may be reimbursed to federally qualified health center (FQHC) and family planning clinic providers for services rendered in the office and outpatient hospital settings.

Procedure code J7301 replaces discontinued procedure code Q0090 and may be reimbursed to FQHC and family planning clinic providers for services rendered to female clients in the office and outpatient hospital settings.

Procedure code 58300 may be reimbursed if billed with procedure code J7300, J7301, or J7302.

Procedure codes J7301 and 87661 will be denied if billed on the same date of service by the same provider as either procedure code 55250 or 58600.

Providers may refer to the current Texas Medicaid Provider Procedures Manual, Gynecological and Reproductive Health and Family Planning Services Handbook, subsection 4.2.2.1, “FQHC Reimbursement for Family Planning Office or Outpatient Visits” subsection 4.2.3, “Laboratory Procedures” and subsection 4.2.5.2, “IUD” for additional information.

Note: Procedure codes 87661 and J7301 are not benefits of the Texas Women’s Health Program.

texaS WoMen’S HealtH PrograM (tWHP) ProviderS

TWHP Providers Benefit ChangesNo benefit changes have been made to the Texas Women’s Health Program (TWHP) in response to the 2014 Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) updates.

Providers may refer to the current Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health and Family Planning Services Handbook, subsection 3.3.6, “Drugs and Supplies” for more information.


DSHS Family Planning Providers/Texas Women's Health Program Providers


cHildren WitH SPecial HealtH care needS (cSHcn) ServiceS PrograM ProviderS

CSHCN Services Program UpdatesThe 2014 Healthcare Common Procedure Coding System (HCPCS) updates including authorization and prior authorization updates for the CSHCN Services Program are included in the HCPCS tables in the “All Code Changes” section of this bulletin beginning on page 20. The 2014 HCPCS deletions and replacements are effective January 1, 2014, for dates of service on or after January 1, 2014, for the CSHCN Services Program. Providers may refer to the “General Information” section for more information.

Authorization and Prior Authorization Update ReminderEffective January 1, 2014, the 2014 HCPCS deleted procedure codes are no longer reimbursed by the CSHCN Services Program. Unless otherwise indicated on page 33 of this bulletin, providers who have received authori-zations or prior authorizations for dates of service that occur on, after, or encompass January 1, 2014, must submit a written request on the appropriate, completed CSHCN Services Program authorization or prior authorization request form in order to update the HCPCS procedure codes authorized for those services.

Providers may refer to the section of this bulletin titled, “Services That Require Authorization or Prior Authoriza-tion,” for information about obtaining authorization or prior authorization.

For more information, call the Texas Medicaid & Healthcare Partnership (TMHP)-CSHCN Services Program Contact Center 1-800-568-2413.

CSHCN Services Program Benefit ChangesThe following CSHCN Services Program benefit changes have been made to support the 2014 HCPCS and Current Procedural Terminology (CPT) updates and are effective for dates of service on or after January 1, 2014. For more information, call the TMHP-CSHCN Services Program Contact Center at 1-800-925-9126.

The policy articles below contain the following information:

• Revised: The description has been revised for these procedure codes. Providers may refer to the appropriate copyright holder for the revised descriptions.

• Discontinued: Discontinued procedure codes are no longer reimbursed after December 31, 2013.

• Added: Added procedure codes are new procedure codes added by the Centers for Medicare & Medicaid Services (CMS). Procedure codes noted with an asterisk (*) require a rate hearing for pricing.

• Limitations: Additional benefit and limitation information for the added procedure codes.

• Replacement: Replacement procedure codes directly replace the indicated discontinued procedure code. The discontinued procedure codes are no longer reimbursed after December 31, 2013, and the replacement procedure codes are effective for dates of service on or after January 1, 2014. Not all discontinued procedure codes have direct replacements.

Note: For the purposes of this section for CSHCN Services Program benefit changes, “advanced practice registered nurse (APRN)” includes nurse practitioner (NP) and clinical nurse specialist (CNS) providers only.


Children With Special Health Care Needs Services Program Providers


Dental – Diagnostic ServicesDiscontinued Procedure CodeD0363

Providers may refer to the current CSHCN Services Program Provider Manual, section 14.2.2.1, “Prior Authoriza-tion Requirements,” section 14.2.2.3, “Cone-Beam Imaging,” and section 14.2.2.5, “Radiographs or Diagnostic Imaging” for additional information.

Dental – Therapeutic Servicesadded Procedure CodesD5863 D5864 D5865 D5866Discontinued Procedure CodesD5860 D5861

Limitations for added procedure codes: Procedure codes D5863, D5864, D5865, or D5866 may be reimbursed for clients who are 6 years of age and older to orthodontist, oral maxillofacial surgeon, and dental providers in the office, inpatient, and outpatient hospital settings.

Prior authorization is required for procedure codes D5863, D5864, D5865, or D5866.

Providers may refer to the current CSHCN Services Program Provider Manual, section 14.2.5.6, “Prosthodontics (Removable) and Maxillofacial Prosthetics,” and section 14.2.5.4, “Endodontics” for additional information.

Doctor of Dentistry Services as a Limited PhysicianDiscontinued Procedure Codes13150 42802

Providers may refer to the current CSHCN Services Program Provider Manual, section 14.2.7.2, “Surgery” for additional information.

Expendable Medical Suppliesadded Procedure CodeT4544

Limitations for added procedure code: Procedure code T4544 may be reimbursed for clients who are 4 years of age and older to durable medical equipment (DME) home health, DME medical supplier, and custom DME providers for services rendered in the home setting.

Revised procedure code T4543 and added procedure code T4544 to replace procedure code T4528 billed with modifier U1 for the 2XL or greater sized incontinence product. Providers must use procedure code T4543 or T4544 to bill for the 2XL or greater adult sized disposable incontinence product. Procedure code T4548 must no longer be billed with modifier U1.

Providers may refer to the current CSHCN Services Program Provider Manual, section 18.2, “Benefits, Limitations and Authorization Requirements” for additional information.

Genetic Testing for Colorectal CancerDiscontinued Procedure CodesS3833 S3834




Providers may refer to the current CSHCN Services Program Provider Manual, section 25.2.5, “Other Laboratory Procedures” and section 25.2.5.2, “Genetic Testing for Colorectal Cancer” for additional information.

Immune Globulinsadded Procedure CodeJ1556


• To physician assistant, (PA), NP, CNS, and physician providers in the office setting

• To medical supplier providers in the home setting


Providers may refer to the current CSHCN Services Program Provider Manual, section 31.2.24.8, “Immune Globulins” for additional information.

Medications – Blood Factor Productsadded Procedure CodeC9133

Limitations for added procedure code: Procedure code C9133 may be reimbursed as follows:

• To PA, NP, CNS, physician, and hemophilia factor providers for services rendered in the office setting

• To hospital and hemophilia factor providers for services rendered in the outpatient hospital setting

Procedure codes J7193, J7194, or J7195 will not be reimbursed if billed on the same day as procedure code C9133.

Providers may refer to the current CSHCN Services Program Provider Manual, section 24.2.1, “Blood Factor Products” and section 24.2.8, “Blood Factor Products” for additional information.

Orthoses and Prostheses

added Procedure CodesL0455 L0457 L0467 L0469 L0641 L0642 L0643 L0648 L0649 L0650 L0651 L1812 L1833 L1848 L3678 L3809 L3916 L3918 L3924 L3930 L4361 L4387 L4397Discontinued Procedure CodeL0430

Limitations for added procedure codes: The added procedure codes listed in the above table may be reimbursed to home health DME, orthotist, prosthetist, and medical supplier providers for services rendered in the home setting.

Providers may refer to the current CSHCN Services Program Provider Manual, section 28.3.2, “Orthotic and Ortho-pedic Devices Procedure Codes” for additional information.

Outpatient Speech-Language Pathology Servicesadded Procedure Codes92521 92522 92523 92524Discontinued Procedure Code92506




Limitations for added procedure codes: Procedure codes 92521, 92522, 92523, and 92524 may be reimbursed as follows:

• To PA, NP, CNS, physician, and Comprehensive Care Program (CCP) providers for services rendered in the office setting

• To physical therapy (PT), occupational therapy (OT), home health agency, and CCP providers for services rendered in the home setting

• To PA, NP, CNS, and physician providers for services rendered in the inpatient setting

• To PA, NP, CNS, physician, hospital, and rehabilitation center providers for services rendered in the outpatient hospital setting

• To PA, NP, CNS, physician, PT, OT, CCP, and rural health clinic (RHC) providers for services rendered in the “other location” setting


Providers may refer to the current CSHCN Services Program Provider Manual, section 36.2, “Benefits, Limitations, and Authorization Requirements” for additional information.

Radiation Therapy Servicesadded Procedure Code77293


• The total component rendered in the office setting may be reimbursed to physicians and radiation treatment centers; services rendered in the outpatient hospital setting may be reimbursed to radiation treatment centers and hospital providers.

• The professional component may be reimbursed to physician providers in the office, inpatient hospital, and outpa-tient hospital settings.

• The technical component may be reimbursed to physicians and radiation treatment centers for services rendered in the office setting. Services rendered in the outpatient hospital setting may be reimbursed to radiation treatment centers and hospital providers.

Procedure code 77293 will be denied if not billed on the same date of service by the same provider as either procedure code 77295 or 77301 even though the work may take place over several days.

Providers may refer to the current CSHCN Services Program Provider Manual, section 33, “Radiation Therapy Services” for additional information.

Surgical - Otheradded Procedure Codes23333 23334 23335 37217 37236 37237 37238 37239 52356 6461664617




Limitations for added procedure codes: The added procedure codes listed in the above table may be reimbursed to physician providers in the office, inpatient and outpatient hospital settings and must include an LT/RT modifier.

Vaccines/Toxoidsadded Procedure Code90673

Limitations for added procedure codes: Procedure code 90673 is limited to clients who are 19 years of age and older and may be reimbursed as follows:

• To APRN, PA, physician, and pharmacist providers for services rendered in the office setting

• To APRN, PA, and physician providers for services rendered in the home and “other location” setting


Procedure code 90673 is limited to once per rolling year, any provider.

Providers may refer to the current CSHCN Services Program Provider Manual, section 31.2.23, “Immunizations (Vaccines and Toxoids)” for additional information.

Wound Care Management Servicesadded Procedure CodesQ4137 Q4138 Q4140 Q4142 Q4143 Q4146 Q4147 Q4148 Q4149

Limitations for added procedure codes: The added procedure codes listed in the above table may be reimbursed as follows:

• To physician, dentist, and podiatrist providers for services rendered in the office setting


Providers may refer to the current CSHCN Services Program Provider Manual, section 31.2.39.2, “Second-Line Wound Care Therapy” for additional information.




all code cHangeS: added, reviSed, rePlaceMent, and diScontinued

2014 HCPCS Procedure Code AdditionsThe following is a list of new Healthcare Common Procedure Coding System (HCPCS) procedure codes that do not replace existing codes:

ToSProcedure Code

Medicaid allowable

CSHCn allowable

authorization requirements

Benefit Changes

2 10030 * * NoneF 10030 * * None2 19081 * * NoneF 19081 * * None2 19082 * * None2 19083 * * NoneF 19083 * * None2 19084 * * None2 19085 * * NoneF 19085 * * None2 19086 * * None2 19281 * * NoneF 19281 * * None2 19282 * * None2 19283 * * NoneF 19283 * * None2 19284 * * None2 19285 * * NoneF 19285 * * None2 19286 * * None2 19287 * * NoneF 19287 * * None2 19288 * * None2 23333 * * None MD, CSHCNF 23333 * * None MD, CSHCN2 23334 * * None MD, CSHCNF 23334 * * None MD, CSHCN2 23335 * * None MD, CSHCN2 33366 * * None

*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.


All Code Changes: Added, Revised, Replacement, and Discontinued


ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

2 34841 * * None2 34842 * * None2 34843 * * None2 34844 * * None2 34845 * * None2 34846 * * None2 34847 * * None2 34848 * * None2 37217 * * None MD, CSHCN2 37236 * * None MD, CSHCNF 37236 * * None MD, CSHCN2 37237 * * None MD, CSHCN2 37238 * * None MD, CSHCNF 37238 * * None MD, CSHCN2 37239 * * None MD, CSHCN2 37241 * * NoneF 37241 NC NC None2 37242 * * None2 37243 * * None2 37244 * * None2 43191 * * None MDF 43191 * * None MD2 43192 * * None MDF 43192 * * None MD2 43193 * * None MDF 43193 * * None MD2 43194 * * NoneF 43194 * * None2 43195 * * NoneF 43195 * * None2 43196 * * NoneF 43196 * * None2 43197 * * None MDF 43197 * * None MD2 43198 * * None MD





ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

F 43198 * * None MD2 43211 * * NoneF 43211 * * None2 43212 * * NoneF 43212 * * None2 43213 * * NoneF 43213 * * None2 43214 * * NoneF 43214 * * None2 43229 * * NoneF 43229 * * None2 43233 * * NoneF 43233 * * None2 43253 * * None MDF 43253 * * None MD2 43254 * * NoneF 43254 * * None2 43266 * * NoneF 43266 * * None2 43270 * * NoneF 43270 * * None2 43274 * * NoneF 43274 * * None2 43275 * * NoneF 43275 * * None2 43276 * * NoneF 43276 * * None2 43277 * * NoneF 43277 * * None2 43278 * * NoneF 43278 * * None2 49405 * * None2 49406 * * None2 49407 * * NoneF 49407 * * None





ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

2 52356 * * None MD, CSHCNF 52356 * * None MD, CSHCN2 64616 * * NoneF 64616 * * None2 64617 * * None MD, CSHCNF 64617 * * None MD, CSHCN2 64642 * * NoneF 64642 * * None2 64643 * * None2 64644 * * NoneF 64644 * * None2 64645 * * None2 64646 * * NoneF 64646 * * None2 64647 * * NoneF 64647 * * None2 66183 * * None8 66183 * * NoneF 66183 * * None6 77293 * * None CSHCNI 77293 * * None CSHCNT 77293 * * None CSHCN5 80155 * * None5 80159 * * None5 80169 * * None5 80171 * * None5 80175 * * None5 80177 * * None5 80180 * * None5 80183 * * None5 80199 * * None5 80203 * * None5 81287 * * None5 81504 * * None5 81507 * NC None*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.




ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

5 87661 * * None MD5 88343 NC NC None1 90673 * * None MD, CSHCNS 90673 * * None MD, CSHCN1 92521 * * None MD, CSHCN1 92522 * * None MD, CSHCN1 92523 * * None MD, CSHCN1 92524 * * None MD, CSHCN2 93582 * * None2 93583 * * None1 94669 NC NC None1 97610 NC NC None1 99446 NC NC None1 99447 NC NC None1 99448 NC NC None1 99449 NC NC None1 99481 NC NC None1 99482 NC NC None9 A4555 NC NC None9 A7047 NC NC None9 A9520 Informational only Informational only None9 A9575 Informational only Informational only None9 A9599 Informational only Informational only None2 C5271 NC NC None2 C5272 NC NC None2 C5273 NC NC None2 C5274 NC NC None2 C5275 NC NC None2 C5276 NC NC None2 C5277 NC NC None2 C5278 NC NC None1 C9133 * * None MD, CSHCN1 C9441 NC NC None1 C9497 NC NC None2 C9735 * * None MD





ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

F C9735 * * None MD2 C9737 NC NC NoneW D0393 NC NC NoneW D0394 NC NC NoneW D0395 NC NC NoneW D0601 Informational Only Informational Only NoneW D0602 Informational Only Informational Only NoneW D0603 Informational Only Informational Only NoneW D1999 NC NC NoneW D2921 NC NC NoneW D2941 NC NC NoneW D2949 NC NC NoneW D3355 NC NC NoneW D3356 NC NC NoneW D3357 NC NC NoneW D3427 NC NC NoneW D3428 NC NC NoneW D3429 NC NC NoneW D3431 NC NC NoneW D3432 NC NC NoneW D4921 NC NC NoneW D5863 * * None MD, CSHCNW D5864 * * None MD, CSHCNW D5865 * * None MD, CSHCNW D5866 * * None MD, CSHCNW D5994 NC NC NoneW D6011 NC NC NoneW D6013 NC NC NoneW D6052 NC NC NoneW D8694 NC NC NoneW D9985 NC NC None9/J E0766 NC NC NoneJ E1352 NC NC None5 G0461 NC NC None5 G0462 NC NC None*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.




ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

1 G0463 NC NC None1 G9187 NC NC None1 G9188 NC NC None1 G9189 NC NC None1 G9190 NC NC None1 G9191 NC NC None1 G9192 NC NC None1 G9193 NC NC None1 G9194 NC NC None1 G9195 NC NC None1 G9196 NC NC None1 G9197 NC NC None1 G9198 NC NC None1 G9199 NC NC None1 G9200 NC NC None1 G9201 NC NC None1 G9202 NC NC None1 G9203 NC NC None1 G9204 NC NC None1 G9205 NC NC None1 G9206 NC NC None1 G9207 NC NC None1 G9208 NC NC None1 G9209 NC NC None1 G9210 NC NC None1 G9211 NC NC None1 G9212 NC NC None1 G9213 NC NC None1 G9214 NC NC None1 G9215 NC NC None1 G9216 NC NC None1 G9217 NC NC None1 G9218 NC NC None1 G9219 NC NC None1 G9220 NC NC None*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.




ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes





ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

1 G9326 NC NC None1 G9327 NC NC None1 G9328 NC NC None1 G9329 NC NC None1 G9340 NC NC None1 G9341 NC NC None1 G9342 NC NC None1 G9343 NC NC None1 G9344 NC NC None1 G9345 NC NC None1 G9346 NC NC None1 G9347 NC NC None1 G9348 NC NC None1 G9349 NC NC None1 G9350 NC NC None1 G9351 NC NC None1 G9352 NC NC None1 G9353 NC NC None1 G9354 NC NC None1 G9355 NC NC None1 G9356 NC NC None1 G9357 NC NC None1 G9358 NC NC None1 G9359 NC NC None1 G9360 NC NC None1 J0151 * * None1 J0401 * * None1 J0717 * * None MD1 J1442 * * None MD1 J1446 NC NC None1 J1556 * * None MD1 J1602 * * None MD1 J3060 * * None1 J3489 * * None1 J7301 * * None MD*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.




ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

1 J7316 * * None1 J7508 NC NC None1 J9047 NC NC None1 J9262 * * None1 J9306 * * None1 J9354 NC NC None1 J9400 * * None1 J9371 * * None9 L0455 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0457 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0467 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0469 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0641 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0642 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0643 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0648 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0649 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0650 * * MD-CCP, CSHCN, MC MD, CSHCN9 L0651 * * MD-CCP, CSHCN, MC MD, CSHCN9 L1812 * * MD-CCP, CSHCN, MC MD, CSHCN9 L1833 * * MD-CCP, CSHCN, MC MD, CSHCN9 L1848 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3678 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3809 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3916 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3918 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3924 * * MD-CCP, CSHCN, MC MD, CSHCN9 L3930 * * MD-CCP, CSHCN, MC MD, CSHCN9 L4361 * * MD-CCP, CSHCN, MC MD, CSHCN9 L4387 * * MD-CCP, CSHCN, MC MD, CSHCN9 L4397 * * MD-CCP, CSHCN, MC MD, CSHCN9 L5969 NC NC None9 L8679 NC NC None1 Q0161 NC NC None1 Q2028 NC NC None*= Texas Medicaid rate hearing required, NC = Procedure code not a benefit, MD in the Authorization Requirements column indicates that a Medicaid prior authorization is required. CSHCN in the Authorization Requirements column indicates that a CSHCN Services Program authorization or prior authorization is required. MC in the Authorization Requirements column indicates that a Medicaid managed care prior authorization is required. None in the Autho-rization Requirements column indicates that authorization or prior authorization is not required.MD in the Benefit Changes column indicates that additional information is available in the Medicaid program benefit changes section at the beginning of this bulletin. CSHCN in the Benefit Changes column indicates that additional information is available in the CSHCN Services Program benefit changes section at the beginning of this bulletin. If the Benefit Changes column is blank, no additional program information is available for the procedure code.




ToSProcedure Code

Medicaid allowable

CSHCn allowable


Benefit Changes

9 Q2052 NC NC None1 Q3027 * * None MD1 Q3028 * * None MD1 Q4137 * * None MD, CSHCN1 Q4138 * * None MD, CSHCN1 Q4139 NC NC None1 Q4140 * * None MD, CSHCN1 Q4141 * * None1 Q4142 * * None MD, CSHCN1 Q4143 * * None MD, CSHCN1 Q4145 NC NC None1 Q4146 * * None MD, CSHCN1 Q4147 * * None MD, CSHCN1 Q4148 * * None MD, CSHCN1 Q4149 * * None MD, CSHCN9 S9960 NC NC None9 S9961 NC NC None9 T4544 * * None MD, CSHCN


Note: All new, revised, and discontinued 2014 HCPCS procedure codes are effective for dates of service on or after January 1, 2014. The new procedure codes that are indicated with an asterisk (*) in the above table are pending a rate hearing and approval of expenditures. Providers will be notified in a future banner or web article if a new procedure code is not approved for reimbursement. Providers can refer to the “Rate Hearings and Expenditure Review” article located in this bulletin for more information about benefits that are pending approval of expenditures.

The following new procedure codes are used for reporting purposes and are informational only:Procedure CodesMedical Procedures0329T 0330T 0331T 0332T 0333T 0337T 9001F 9002F 9003F 9004F9005F 9006F 9007FSurgical Procedures0334T 0335T 0336T 0338T 0340T 0341T 0342T 0343T 0344T 0345TRadiological Procedures0346T

For more information, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.




Discontinued Procedure CodesThe 2014 HCPCS discontinued procedure codes are no longer reimbursed after December 31, 2013. The following is a list of procedure codes that have been discontinued:

Procedure Codes13150 19102 19103 19290 19291 19295 23331 23332 32201 3720437205 37206 37207 37208 37210 42802 43219 43228 43256 4325843267 43268 43269 43271 43272 43456 43458 44901 47011 4851149021 49041 49061 50021 58823 64613 64614 75960 77031 7703292506 C1204 C1879 C9130 C9131 C9292* C9294* C9295 C9296* C9297*C9298* C9736 D0363 D3354 D5860 D5861 G0275 G8459 G8462 G8463G8553 G8556 G8557 G8558 G8588 G8589 G8590 G8591 G8592 G8596G8603 G8604 G8605 G8606 G8607 G8608 G8609 G8610 G8611 G8612G8613 G8614 G8615 G8616 G8617 G8618 G8619 G8620 G8621 G8622G8623 G8624 G8625 G8626 G8642 G8643 G8644 G8741 G8742 G8743G8744 G8745 G8746 G8747 G8748 G8790 G8791 G8792 G8793 G8794G8795 G8796 G8799 G8800 G8801 G8812 G8813 G8814 G8827 G8835G8919 G8920 G8921 G8922 G8945 G8954 J0152 J0718 J1440 J1441J3487 J3488 J9002 L0430 Q0090* Q0165 Q0168 Q0170 Q0171 Q0172Q0176 Q0178 Q0505 Q2027 Q2051 Q3025 Q3026 S3625 S3626 S3833S3834

The procedure codes indicated with an asterisk (*) have been replaced. Replacement procedure codes are available for the Texas Medicaid Program, the CSHCN Services Program, or both. Providers may refer to the Replacement Procedure Codes section on page 33 of this bulletin for details.

The following informational reporting procedure codes have been discontinued:Procedure Codes0078T 0079T 0080T 0081T 0124T 0183T 0185T 0186T 0192T 0260T0261T 0318T

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.

Replacement Procedure CodesEffective for dates of service on or after January 1, 2014, the following discontinued procedure codes have been replaced by the corresponding replacement procedure codes:

replacement codes

Discontinued codes Medicaid rate CSHCn rate

authorization requirement

J1556 C9130 $64.42 $64.42 NoneJ3060 C9294 $31.31 $31.31 NoneJ7301 Q0090 $698.44 $698.44 NoneJ7316 C9298 $1060.57 $1060.57 NoneJ9047 C9295 NC NC None

* = Texas Medicaid rate hearing required, NC = Procedure code not a benefit




replacement codes

Discontinued codes Medicaid rate CSHCn rate

authorization requirement

J9262 C9297 $2.86 $2.86 NoneJ9306 C9292 $98.98 $98.98 NoneJ9354 C9131 NC NC NoneJ9400 C9296 * * None

* = Texas Medicaid rate hearing required, NC = Procedure code not a benefit


Procedure Code Description ChangesEffective for dates of service on or after January 1, 2014, the following procedure code descriptions have changed:

Procedure Codes01963 12031 12032 12034 12035 12036 12037 19301 20527 2055021015 21016 21557 21558 21935 21936 22315 22325 22326 2232722328 22586 22633 22634 22904 22905 23077 23078 24077 2407924160 24164 24357 24358 24359 24586 24587 25077 25078 2552026040 26045 26117 26118 26341 26350 26352 26356 26357 2635827027 27049 27057 27059 27329 27345 27364 27400 27615 2761627632 27826 27827 27828 28046 28047 29889 31540 31541 3164831649 31730 32200 33222 33223 35103 37214 42510 42894 4320043201 43202 43204 43205 43206 43215 43216 43217 43220 4322643227 43231 43232 43235 43236 43237 43238 43239 43240 4324143242 43243 43244 43245 43246 43247 43248 43249 43250 4325143252 43255 43257 43259 43260 43263 43264 43265 43450 4375243753 44800 44899 44900 47010 47552 48510 49020 49040 4906050020 50391 50545 50690 51605 53060 53250 53270 53431 5642056440 56740 58140 58145 61591 63075 63076 63077 63078 6445565290 65778 65779 67515 67908 69210 72040 72270 74022 7417675791 77295 77326 78290 78708 80047 80048 80050 80051 8005380055 80061 80069 80074 80076 80400 80402 80406 80408 8041080412 80414 80415 80416 80417 80418 80420 80422 80424 8042680428 80430 80432 80434 80435 80436 80438 80439 80440 8050080502 81252 81253 81355 81371 81376 81382 81400 81401 8140281403 81404 81405 81406 81407 81408 81503 81506 82541 8254282543 82544 82777 83915 84112 87498 87521 87522 87535 8753687538 87539 87631 88045 88302 88304 88305 88307 88309 8836088361 90375 90654 90655 90656 90657 90660 90672 90700 9070290882 90889 90947 91010 91013 91065 92083 92941 93653 9365493656 93922 95905 95907 95908 95909 95910 95911 95912 9591396101 96116 96118 96125 96375 96376 98960 98961 98962 9907199091 99143 99144 99145 99170 99201 99202 99203 99204 99205




Procedure Codes99212 99213 99214 99215 99217 99218 99219 99220 99221 9922299223 99224 99225 99226 99231 99232 99233 99234 99235 9923699241 99242 99243 99244 99245 99251 99252 99253 99254 9925599281 99282 99283 99284 99285 99304 99305 99306 99307 9930899309 99310 99318 99324 99325 99326 99327 99328 99334 9933599336 99337 99339 99340 99341 99342 99343 99344 99345 9934799348 99349 99350 99374 99375 99377 99378 99379 99380 9939199392 99393 99394 99395 99396 99397 99444 99450 99455 9945699495 99496 A5081 A9272 C2618 C9734 D0350 D2950 D3351 D3352D3410 D3421 D3425 D3426 D4920 D5991 D6080 D8693 D9210 E0601E2300 E2301 G0416 G0417 G0418 G0419 G8126 G8127 G8417 G8418G8419 G8420 G8421 G8422 G8427 G8428 G8430 G8431 G8433 G8442G8451 G8509 G8510 G8511 G8535 G8539 G8540 G8542 G8543 G8569G8570 G8682 G8683 G8685 G8709 G8722 G8730 G8731 G8733 G8768G8772 G8775 G8778 G8781 G8784 G8808 G8810 G8880 G8882 G8887G8891 G8892 G8928 G8929 G8938 G8939 G8940 G8941 G8942 G8946G8950 G8951 G8968 G8969 G8985 G8990 G8991 G8992 G8993 G8994G8995 G8996 G8997 G8998 G8999 G9158 G9159 G9160 G9161 G9162G9163 G9164 G9165 G9166 G9167 G9168 G9169 G9170 G9171 G9172G9173 G9174 G9175 G9176 G9186 J7507 L0120 L0160 L0172 L0174L0450 L0454 L0456 L0460 L0466 L0468 L0621 L0623 L0625 L0626L0627 L0628 L0630 L0631 L0633 L0637 L0639 L0980 L0982 L0984L1600 L1610 L1620 L1810 L1830 L1832 L1836 L1843 L1845 L1847L1850 L1902 L1904 L1906 L1907 L3100 L3170 L3650 L3660 L3670L3675 L3677 L3710 L3762 L3807 L3908 L3912 L3915 L3917 L3923L3925 L3927 L3929 L4350 L4360 L4370 L4386 L4396 L4398 L5668Q5001 Q5002 Q5009 S0182 S3870 T4543

The descriptions of the following informational reporting procedure codes have changed:reporting Procedure Codes - Informational1050F 1052F 1055F 1060F 1061F 1065F 1066F 1070F 1071F 1090F1091F 1100F 1101F 1110F 1111F 1116F 1118F 1119F 1121F 1123F1124F 1125F 1126F 1127F 1128F 1130F 1134F 1135F 1136F 1137F1150F 1151F 1152F 1153F 1157F 1158F 1159F 1160F 1170F 1175F1180F 1181F 1182F 1183F 1200F 1205F 1220F 1400F 1450F 1451F1460F 1461F 1490F 1493F 1494F 1500F 1501F 1502F 1503F 1504F1505F 2000F 2001F 2002F 2004F 2010F 2014F 2015F 2016F 2018F2019F 2020F 2021F 2022F 2024F 2026F 2027F 2029F 2030F 2031F2035F 2040F 2044F 2050F 2060F 3006F 3008F 3011F 3014F 3015F3016F 3017F 3018F 3019F 3020F 3021F 3022F 3023F 3025F 3027F3028F 3035F 3037F 3038F 3040F 3042F 3044F 3045F 3046F 3048F3049F 3050F 3055F 3056F 3060F 3061F 3062F 3066F 3072F 3073F3074F 3075F 3077F 3078F 3079F 3080F 3082F 3083F 3084F 3085F


Prior Authorization Changes


reporting Procedure Codes - Informational3088F 3089F 3090F 3091F 3093F 3095F 3096F 3100F 3110F 3111F3112F 3115F 3117F 3118F 3119F 3120F 3125F 3130F 3132F 3140F3141F 3142F 3150F 3155F 3160F 3170F 3200F 3210F 3215F 3230F3250F 3260F 3265F 3267F 3268F 3269F 3270F 3271F 3272F 3273F3274F 3278F 3279F 3280F 3281F 3284F 3285F 3288F 3290F 3291F3292F 3293F 3294F 3300F 3301F 3315F 3316F 3317F 3318F 3319F3320F 3321F 3322F 3323F 3324F 3325F 3328F 3330F 3331F 3340F3341F 3342F 3343F 3344F 3345F 3350F 3351F 3352F 3353F 3354F3370F 3372F 3374F 3376F 3378F 3380F 3382F 3384F 3386F 3388F3390F 3394F 3395F 3450F 3451F 3452F 3455F 3470F 3471F 3472F3475F 3476F 3491F 3494F 3495F 3496F 3497F 3498F 3510F 3511F3512F 3513F 3514F 3515F 3517F 3520F 3550F 3551F 3552F 3555F3570F 3572F 3573F 3650F 3700F 3720F 3725F 3750F 3751F 3752F3753F 3754F 3755F 3756F 3757F 3758F 3759F 3760F 3761F 3762F3763F 4000F 4001F 4003F 4004F 4005F 4008F 4010F 4011F 4012F4013F 4014F 4015F 4016F 4017F 4018F 4019F 4025F 4030F 4033F4035F 4037F 4040F 4042F 4043F 4044F 4045F 4046F 4047F 4048F4049F 4050F 4051F 4052F 4053F 4054F 4055F 4056F 4058F 4060F4062F 4063F 4064F 4065F 4066F 4067F 4069F 4073F 4075F 4077F4079F 4084F 4086F 4090F 4095F 4100F 4110F 4115F 4120F 4124F4130F 4131F 4132F 4133F 4134F 4135F 4136F 4140F 4142F 4144F4148F 4151F 4155F 4157F 4163F 4164F 4165F 4167F 4168F 4169F4171F 4172F 4174F 4175F 4176F 4177F 4178F 4179F 4180F 4181F4182F 4185F 4186F 4187F 4188F 4189F 4190F 4191F 4192F 4193F4194F 4195F 4196F 4200F 4201F 4210F 4220F 4221F 4230F 4240F4242F 4245F 4248F 4250F 4255F 4256F 4260F 4261F 4265F 4266F4267F 4268F 4269F 4270F 4271F 4274F 4279F 4280F 4290F 4293F4300F 4301F 4305F 4306F 4320F 4322F 4324F 4325F 4326F 4328F4330F 4340F 4350F 4400F 4450F 4470F 4480F 4481F 4500F 4510F4525F 4526F 4540F 4541F 4550F 4551F 4552F 4553F 4554F 4555F4556F 4557F 4558F 4559F 4560F 4561F 4562F 4563F 5005F 5010F5015F 5020F 5050F 5060F 5062F 5100F 5200F 5250F 6005F 6010F6015F 6020F 6030F 6040F 6045F 6070F 6080F 6090F 6100F 6101F6102F 6110F 6150F 7010F 7020F 7025F

Providers must contact the appropriate copyright holder to obtain procedure code descriptions.





ModifiersThe following table lists new, revised, and discontinued modifiers:

new ModifierPMrevised ModifierHI

New modifiers are effective for dates of service on or after January 1, 2014. Providers may contact the appropriate copyright holder to obtain modifier descriptions.

Prior autHorization cHangeS

Authorization or Prior AuthorizationFor procedure codes that require authorization or prior authorization but are awaiting a rate hearing and approval of expenditures, providers must follow the established authorization or prior authorization processes as defined in the following:

• Current Texas Medicaid Provider Procedures Manual

• Current CSHCN Services Program Provider Manual

• Articles published on the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com

Note: This article applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorization and reimbursement.

Providers must obtain a timely authorization or prior authorization for the service that they provide. Services that are submitted without the proper authorization are denied.

Providers are responsible for meeting all filing deadlines and ensuring that the authorization or prior authoriza-tion number appears on the claim and that the appropriate documentation is submitted with the claim. Retroactive authorization requests for certain services will not be granted, unless otherwise indicated in the applicable autho-rization requirements sections of the current Texas Medicaid Provider Procedures Manual or the current CSHCN Services Program Provider Manual.

The procedure codes that require authorization or prior authorization are indicated in the Authorization Require-ments column of the 2014 HCPCS Procedure Code Additions table that begins on page 20 of this bulletin.

Important: Authorization or prior authorization is a condition for reimbursement; it is not a guarantee of payment.

Prior Authorization UpdateProviders who have received prior authorization for any of the following 2014 Healthcare Common Procedure Coding System (HCPCS) discontinued procedure codes for dates of service that occur on, after, or encompass January 1, 2014, must contact the TMHP Prior Authorization Department to update the procedure codes that are prior authorized for those services:




http://www.tmhp.com

ToS Discontinued Procedure Code Prior authorization requirements2/7/8/F 13150 CSHCN2/8/F 19102 CSHCN2/8/F 19103 CSHCN2/8/F 19295 CSHCN2/7/8/F 23331 CSHCN2/8/F 37204 CSHCN2/8/F 37205 CSHCN2/8/F 37206 CSHCN2/8/F 37207 CSHCN2/8/F 37208 CSHCN2/7/8/F 42802 CSHCN2/7/8/F 43219 CSHCN2/7/8/F 43228 CSHCN2/8/F 43256 CSHCN2/7/8/F 43258 CSHCN2/7/8/F 43267 CSHCN2/7/8/F 43268 CSHCN2/7/8/F 43269 CSHCN2/7/8/F 43271 CSHCN2/7/8/F 43272 CSHCN2/7/8/F 43456 CSHCN2/8/F 43458 CSHCN2/8/F 47011 CSHCN2/8/F 48511 CSHCN2/8/F 49021 CSHCN2/8/F 49041 CSHCN2/8/F 49061 CSHCN2/8/F 50021 CSHCN2/8/F 64613 CSHCN2/8/F 64614 CSHCNW D0363 MD, MC, CSHCN9/W D5860 CSHCN9/W D5861 CSHCN9 L0430 CSHCN5/G/I/T S3833 MD, CSHCN5/G/I/T S3834 MD, CSHCNTOS = Type of service, CSHCN = Prior authorization required for the CSHCN Services Program, MD = Prior authorization required for Texas Medicaid, MC = Managed care prior authorization required.

For a list of Prior Authorization Department telephone numbers, providers may refer to the “TMHP Telephone and Address Guide” in the current Texas Medicaid Provider Procedures Manual, Vol. 1, (General Information), on page vii, and TMHP-CSHCN Services Program Contact Information” in the current CSHCN Services Program Provider Manual, on page 1-2.




hcpcs special bulletin - tmhpjanuary 2014 no. 6 2014 healthcare common procedure coding system...

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