ICD-10 Special Bulletin
2015 International Classification of Diseases, Tenth Revision, Special Bulletin
MAY 2015
NO. 8
GENERAL INFORMATION
2015 ICD-10 Implementation
On October 1, 2015, the Texas Medicaid & Healthcare Partnership (TMHP) will apply the 2015 annual International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) updates that are effective for dates
of service on or after October 1, 2015, and the International Classification of Diseases, Tenth Revision, Procedure Coding
System (ICD-10-PCS) updates that are effective for inpatient hospital dates of admission on or after October 1, 2015.
This special bulletin includes the ICD-10 updates for Texas Medicaid, the Children with Special Health Care
Needs (CSHCN) Services Program, the Department of State Health Services (DSHS) Family Planning Program
(DFPP), and the Texas Women’s Health Program (TWHP). This bulletin is intended to notify providers of
program and coding changes related to the 2015 updates for ICD-10-CM and ICD-10-PCS.
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.
Important: At this time, the lists in this bulletin that identify the ICD-10-CM replacements for specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes may not be
all-inclusive. As medical policies continue to be updated, the list or lists of ICD-10-CM diagnosis codes for specific
benefits are subject to change. Providers will be notified if lists change.
Note: This bulletin does not contain a complete list of ICD-10-CM diagnosis codes or ICD-10-PCS surgical procedure
codes. The complete list of 2015 ICD-10 codes can be found in the 2015 ICD-10 coding manual available through the
Centers for Medicare & Medicaid Services (CMS).
Date of Admission Versus Date of Discharge
Inpatient hospital claims must be coded according to the date of discharge, instead of the date of
admission, as is current practice:
• If the client is discharged on or before September 30, 2015, ICD-9-CM diagnosis and surgical
procedure codes must be submitted on the claim.
• If the client is discharged on or after October 1, 2015, ICD-10-CM diagnosis codes and
ICD-10-PCS surgical procedure codes must be submitted on the claim.
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INSIDE
General Information
1
2015 ICD-10 Implementation........................................................................................................................................................................1
Date of Admission Versus Date of Discharge..........................................................................................................................................1
ICD-10 Organization and Coding Structure........................................................................................................................................... 3
Claims Filing and Appeals............................................................................................................................................................................. 5
Claim Forms: Paper and Electronic Submissions.................................................................................................................................. 6
Authorization and Prior Authorization Updates................................................................................................................................... 6
Medicaid Fee-For-Service and Managed Care Providers
7
Texas Medicaid Benefit Changes.................................................................................................................................................................7
Code Updates Web Page...............................................................................................................................................................................7
Diagnostic Doppler Sonography.............................................................................................................................................................26
Behavioral Health Services
84
ICD-10 and DSM Diagnosis Codes for Behavioral Health Services...............................................................................................84
Texas Health Steps (THSteps) Medical Providers
106
THSteps Medical Benefit Changes.........................................................................................................................................................106
Texas Health Steps (THSteps) Dental Providers
107
THSteps Dental Benefit Changes...........................................................................................................................................................107
Home Health Providers
108
Home Health Benefit Changes.............................................................................................................................................................. 108
Respiratory Equipment and Supplies–Home Health......................................................................................................................110
Comprehensive Care Program (CCP) Providers
111
CCP Benefit Changes...................................................................................................................................................................................111
Texas Medicaid Forms
115
Prior Authorization Forms........................................................................................................................................................................ 115
DSHS Family Planning Program Providers
116
DSHS Family Planning Program Benefit Changes............................................................................................................................ 116
Texas Women’s Health Program (WHP) Providers
116
TWHP Benefit Changes.............................................................................................................................................................................. 116
Medical Transportation Program (MTP) Providers
117
MTP Benefit Changes..................................................................................................................................................................................117
Inpatient Hospital ICD-10-PCS Surgical Procedure Code Updates 117
ICD-10 and DRG Code Changes for Inpatient Hospital Providers...............................................................................................117
CSHCN Services Program Providers
118
CSHCN Services Program Benefit Changes........................................................................................................................................118
CSHCN Services Program Forms
144
Changes to Forms....................................................................................................................................................................................... 144
General Information
ICD-10 Organization and Coding Structure
The new ICD-10 classification system provides significant improvements by capturing greater detailed information
as code descriptions are more specific and will have the ability to expand and capture additional advancements in
clinical medicine in the future. ICD-10 consists of the following two coding sets:
• ICD-10-CM is the diagnosis classification system developed by the Centers for Disease Control and Prevention
(CDC) for use in all United States health care treatment settings. Diagnosis coding under this system uses 3–7
alpha and numeric digits and full code titles, but the format is very much the same as International Classification
of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM).
• ICD-10-PCS is the procedure classification system developed by CMS for use in the United States for surgical
services rendered in the inpatient hospital settings only. The new procedure coding system uses 7 alpha or
numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.
The following table outlines the differences between the ICD-9-CM system and the ICD-10-CM/PCS system:
Type of Code ICD-9-CM
ICD-10
Diagnosis
codes
• 3-5 digits
• Approximately 13,000 codes
• Digit 1 is either alpha (E or V) or
numeric
• Digit 2-5 are numeric
• The decimal is after the third digit
Surgical
procedure
codes
• 3-4 digits
• Approximately 3,000 codes
• Each digit is numeric
• No decimals
• 3-7 digits
• Approximately 68,000 codes
• Digit 1 is an alpha-character
• Digit 2 is a numeric character
• Digits 3-7 are either alpha or numeric (alpha
digits are not case sensitive)
• The letter U is not used
• The decimal is after the third digit
• 7 digits
• Approximately 87,000 available codes
• Each digit is either alpha or numeric (alpha digits
are not case sensitive and letters O and I are not
used to avoid confusion with numbers 0 and 1)
• No decimals
Providers may refer to the following resources for more information about ICD-10 organization and coding structure:
• The CMS ICD-10 web page at www.cms.gov/Medicare/Coding/ICD10/index.html.
• The TMHP Code Updates — ICD-10 Implementation web page at www.tmhp.com/Pages/CodeUpdates/ICD-10.aspx.
Combination Diagnosis Codes
There are two types of combination diagnosis codes in the ICD-10 coding system:
• A single diagnosis code that describes the condition and the cause and intent in one code descriptor including any
associated secondary condition(s).
More than one diagnosis code is required to fully describe a diagnosis and an associated complication that is
not included in the description of the single code. In the Texas Medicaid and CSHCN Services Program benefit
sections within this bulletin, TMHP refers to these code pairs as “combinations” or “combination codes,” and
requires that both diagnosis codes be present on the claim for consideration of reimbursement.
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
General Information
Code pairs should not be used when the classification provides a single code that clearly identifies all the elements
documented in the diagnosis. When a single code lacks necessary specificity in describing the manifestation or
complication, an additional code should be used as a secondary code.
Important: To avoid fraudulent billing, providers must submit the diagnosis code or codes that are most appropriate for
the services provided. Claims are subject to retrospective review, and payments may be recouped (i.e., deducted from the
provider’s weekly payment) if correct coding is not used, including, but not limited to, combination diagnosis codes.
Enhancements
ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease
classification are updated to be consistent with current clinical practice. Non-specific codes are still available for use
when medical record documentation does not support a more specific code.
The following new features can be found in ICD-10-CM:
• Laterality (Left, Right, Bilateral)
Note: Providers must continue to submit the appropriate LT, RT, or 50 modifier with the procedure code as applicable.
The laterality of the ICD-10 diagnosis codes does not replace the modifier coding requirement for specific procedure codes.
• Combination codes for certain conditions and common associated symptoms and manifestations as well as
combination codes for poisonings and their associated external cause
• Obstetric codes identify trimester instead of episode of care
• Character “X” is used as a 5th character placeholder in certain 6-character codes to allow for future expansion
and to fill in other empty characters when a code that is less than 6 characters in length requires a 7th character
• Two types of Excludes notes
• Inclusion of clinical concepts that do not exist in ICD-9-CM (e.g., under-dosing, blood type, blood alcohol level)
• A number of codes are significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications)
• Codes for postoperative complications are expanded and a distinction is made between intraoperative complications and post-procedural disorders
Additionally, the following changes can be found in ICD-10-CM:
• Injuries are grouped by anatomical site rather than by type of injury.
• Category restructuring and code reorganization occur in a number of ICD-10-CM chapters, resulting in the
classification of certain diseases and disorders that are different from ICD-9-CM.
• Certain diseases are reclassified to different chapters or sections to reflect current medical knowledge.
• New code definitions (for example, definition of acute myocardial infarction is now 4 weeks rather than 8 weeks).
• The codes corresponding to ICD-9-CM “V” codes (Factors Influencing Health Status and Contact with Health
Services) and “E” codes (External Causes of Injury and Poisoning) are incorporated into the main classification
(in ICD-9-CM they were separated into supplementary classifications).
• Full descriptions are used.
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
General Information
• Extensions specify encounter – ICD-10-CM has added code alpha character extensions (seventh character) in
appropriate sections to provide specific information about the characteristics of the encounter. Extensions have
different meanings depending on the section.
• Standard definitions have been added to facilitate the coding process.
Notable Classifications
Behavioral Health Services
ICD-10 diagnosis coding is more closely aligned with the Diagnostic and Statistical Manual of Mental Disorders
(DSM) diagnosis coding. ICD-10 diagnosis codes must be used to submit claims for services rendered.
Providers are encouraged to be aware of the similarities and differences between ICD-10 and DSM diagnosis
coding, but DSM diagnosis codes are not compliant with Health Insurance Portability and Accountability Act
(HIPAA) claim coding regulations and must not be used to submit claims. Claims that are submitted with DSM
diagnosis codes will not be reimbursed.
All medical record documentation requirements will continue to apply on or after October 1, 2015, including the
requirement to document the appropriate DSM diagnosis codes in the client’s medical record.
Substance Abuse, Use, and Dependency
ICD-10-CM diagnosis codes for substance abuse, use, and dependence are more specific to the level of service.
Claims Filing and Appeals
Professional and outpatient services rendered on or before September 30, 2015, must be submitted separately from
services rendered on or after October 1, 2015. The following applies:
• Dates of service on or before September 30, 2015, must be submitted on one claim.
• Dates of service on or after October 1, 2015, must be submitted on a separate claim.
Effective for dates of service on or after October 1, 2014, inpatient hospital claims must be coded according to
the date of discharge. For the transition from ICD-9 to ICD-10 effective October 1, 2015, providers must code
diagnoses as follows:
• If the client is discharged on or before September 30, 2015, ICD-9-CM diagnosis and surgical procedure codes
must be submitted on the claim.
• If the client is discharged on or after October 1, 2015, ICD-10-CM diagnosis codes and ICD-10-PCS surgical
procedure codes must be submitted on the claim.
Inpatient Hospital Surgical Procedure Coding
The ICD-10-PCS procedure codes are inpatient hospital surgical procedure codes and must be submitted, as applicable, only on inpatient hospital claims.
Note: For professional and outpatient procedures and services, providers must continue to use the American Medical
Association (AMA) Current Procedural Terminology (CPT) manual and the CMS Health Care Common Procedure
Coding System (HCPCS) manual.
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
General Information
Claim Forms: Paper and Electronic Submissions
TexMedConnect and the TMHP Electronic Data Interchange (EDI) has been updated to accommodate 5010
transactions and ICD-10 coding structures and can now accept ICD-9-CM codes and ICD-10 codes as necessary.
The following paper claim forms have also been updated to accommodate the new ICD-10 coding structure. The
new forms are effective as follows:
Form
2012 ADA Dental paper claim form
Effective Date
January 1, 2014
TMHP website article: Correction To “Changes to Dental Claim Form Submissions
Effective January 1, 2014”
Information posted December 13, 2013
CMS-1500 paper claim form
January 6, 2014
TMHP website articles: Updated CMS-1500 Claim Form to be Accepted Beginning
January 6, 2014, Information posted November 15, 2013
Correction to “Updated CMS-1500 Claim Form Will be Accepted Beginning
January 6, 2014” Information posted December 13, 2013
Family Planning 2017 Claims Form
April 1, 2014
TMHP website article: TBD
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Authorization and Prior Authorization Updates
Effective October 1, 2015, for dates of service on or after October 1, 2015, the ICD-9-CM diagnosis and surgical
procedure codes will no longer be accepted by Texas Medicaid or the CSHCN Services Program.
Effective October 1, 2015, regardless of the requested dates of service, providers must include ICD-10-CM
diagnosis codes when submitting prior authorization requests to TMHP. Prior authorization requests must be
submitted as follows:
Diagnosis Coding
Receipt Date
ICD-9-CM procedure codes
Received by TMHP on or before September 30, 2015
ICD-10-PCS procedure codes
Received by TMHP on or after October 1, 2015
The prior authorization request forms have been updated for ICD-10 and posted to this website.
For Authorizations that are placed in pending status on or before September 30, 2015, information received on or
after October 1, 2015, must adhere to the deadlines identified in the above table.
Reminder: Services that are submitted without the appropriate prior authorization will be denied. Providers are
responsible for meeting all filing deadlines and for ensuring that the authorization or prior authorization number
appears on the claim or that the appropriate documentation is submitted with the claim.
Important: Authorization or prior authorization is a condition for reimbursement; it is not a guarantee of payment.
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, Section 1.1, on page 1-2.
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Code Updates Web Page
Providers are encouraged to refer to the TMHP Code Updates – ICD-10 Implementation web page at
www.tmhp.com/Pages/CodeUpdates/ICD-10.aspx for all notifications about the 2015 ICD-10 implementation.
MEDICAID FEE-FOR-SERVICE AND MANAGED CARE PROVIDERS
Texas Medicaid Benefit Changes
The following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are
effective for dates of service on or after October 1, 2015.
For questions, call the TMHP Contact Center at 1-800-925-9126.
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 authorizations,
and reimbursement.
Aerosol Treatment Outpatient Setting
Procedure codes 94640, 94644, and 94645 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B59
E840
E8411
E8419
E848
E849
J09X1
J09X2
J121
J15212
J188
J189
J210
J211
J218
J219
J398
J410
J411
J418
J42
J430
J431
J432
J438
J439
J440
J441
J449
J4520
J4521
J4522
J4530
J4531
J4532
J4540
J4541
J4542
J4550
J4551
J4552
J45901
J45902
J45909
J45990
J45991
J45998
J471
J479
J670
J671
J672
J673
J674
J675
J676
J677
J678
J679
J690
J691
J698
J705
J95851
J9801
J9809
K449
P270
P271
P278
T50995A T50995D T50995S
Procedure codes J7605, J7608, J7622, J7626, J7631, J7633, J7639, J7644, and J7682 may be reimbursed when they
are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A150
E840
J09X1
J09X2
J121
J15212
J188
J189
J210
J211
J218
J219
J410
J411
J418
J42
J430
J431
J432
J438
J439
J440
J441
J449
J4520
J4521
J4522
J4530
J4531
J4532
J4540
J4541
J4542
J4550
J4551
J4552
J45901
J45902
J45909
J45990
J45991
J45998
J471
J479
J60
J61
J620
J628
J630
J631
J632
J633
J634
J635
J64
J660
J661
J662
J668
J670
J671
J672
J673
J674
J675
J676
J677
J678
J679
J680
J681
J682
J683
J684
J689
J690
J691
J698
J700
J701
J705
J708
J709
J9801
Q334
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Reimbursement for aerosol pentamidine treatment is limited to the following diagnoses:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A481
B20
B4481
B59
B9733
B9734
B9735
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.3, “Aerosol Treatment” for additional information.
Alglucosidase Alfa
Alglucosidase alfa procedure codes J0220 and J0221 may be prior authorized for clients of any age with a diagnosis
of glycogen storage disease Type II (GSD Type II) (Pompe disease). The most appropriate ICD-10 diagnosis code
must be indicated on the prior authorization request and on the claim.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.41.3, “Alglucosidase Alfa (Myozyme),” for additional information.
Allergen Immunotherapy
Procedure codes 95115, 95117, 95145, 95146, 95147, 95148, 95149, 95165, and 95170 may be reimbursed when they
are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H1045
H65191
H65192
H65193
H65194
H65195
H65196
H6501
H6502
H6503
H6504
H6505
H6506
H65111
H65112
H65113
H65114
H65115
H65116
H65491
H65492
H65493
J301
J305
J3081
J309
J4520
J4530
J4540
J4550
J4552
J45902
J45909
J45998
L500
T531X4D
T532X4D
T533X4D
T534X4D
T536X4D
T59812D
T63001A
T63002A
T63003A
T63003D
T63003S
T63004A
T63004D
T63004S
T63011A
T63011D
T63011S
T63012A
T63013A
T63014A
T63021A
T63022A
T63023A
T63023D
T63023S
T63024A
T63024D
T63024S
T63031A
T63031D
T63031S
T63032A
T63033A
T63034A
T63041A
T63042A
T63043A
T63043D
T63043S
T63044A
T63044D
T63044S
T63061A
T63061D
T63062A
T63063A
T63063D
T63064A
T63064D
T63064S
T63071A
T63071D
T63072A
T63073A
T63073D
T63073S
T63074A
T63074D
T63074S
T63081A
T63081D
T63081S
T63082A
T63083A
T63083D
T63084A
T63084D
T63084S
T63091A
T63091D
T63092A
T63093A
T63093D
T63093S
T63094A
T63094D
T63094S
T63111A
T63111D
T63112A
T63113A
T63113S
T63113D
T63114A
T63114D
T63114S
T63121A
T63121D
T63122A
T63123A
T63123D
T63123S
T63124A
T63124D
T63124S
T63191A
T63191D
T63192A
T63193A
T63193D
T63193S
T63194A
T63194D
T63194S
T632X1A
T632X1D
T632X2A
T632X3A
T632X3D
T632X3S
T632X4A
T632X4D
T632X4S
T63301A
T63301D
T63302A
T63303A
T63303D
T63304A
T63304D
T63304S
T63311A
T63311D
T63312A
T63313A
T63314A
T63314D
T63314S
T63321A
T63321D
T63322A
T63323A
T63323D
T63323S
T63324A
T63324D
T63324S
T63331A
T63331D
T63332A
T63333A
T63333D
T63333S
T63334A
T63334D
T63334S
T63391A
T63391D
T63392A
T63393A
T63393D
T63393S
T63394A
T63394D
T63394S
T63411A
T63411D
T63412A
T63413A
T63413D
T63414A
T63414D
T63414S
T63421A
T63421D
T63422A
T63423A
T63423D
T63424A
T63424D
T63424S
T63431A
T63431D
T63432A
T63433A
T63433D
T63434A
T63434D
T63434S
T63441A
T63441D
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T63442A
T63443A
T63443D
T63444A
T63444D
T63452A
T63453A
T63453D
T63453S
T63454A
T63461D
T63462A
T63463A
T63463D
T63463S
T63481A
T63481D
T63482A
T63483A
T63483D
T63484S
T63511A
T63511D
T63512A
T63513A
T63592A
T63593A
T63594A
T63611A
T63611D
T63621A
T63621D
T63622A
T63623A
T63624A
T63633A
T63634A
T63691A
T63691D
T63692A
T63711D
T63712A
T63713A
T63714A
T63791A
T63794A
T63811A
T63811D
T63812A
T63813A
T63822A
T63823A
T63824A
T63831A
T63831D
T63891A
T63891D
T63892A
T63893A
T63894A
T6393XA
T6394XA
T65824D
T63444S
T63454D
T63464A
T63483S
T63514A
T63612A
T63631A
T63693A
T63791D
T63814A
T63832A
T6391XA
T63451A
T63454S
T63464D
T63484A
T63591A
T63613A
T63631D
T63694A
T63792A
T63821A
T63833A
T6391XD
T63451D
T63461A
T63464S
T63484D
T63591D
T63614A
T63632A
T63711A
T63793A
T63821D
T63834A
T6392XA
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.4.1, “Allergy Immunotherapy,” for additional information.
Ambulance Services
Effective for dates of service on or after October 1, 2015, the following condition codes must be used to identify
emergency medical conditions for ambulance transports:
Ambulance Emergency Condition Codes
B9689
B999
E869
G8929
H579
I469
R002
R0602
R0689
R238
R4182
R4189
R58
R6889
R7309
T50904A
T59891A
T5994XA
T751XXA
T754XXA T782XXA
Y828
Z209
Z7401
F068
I499
R079
R4589
S0590XA
T672XXA
T7840XA
Z779
F10929
J9600
R092
R509
T07
T675XXA
T8189XA
Z9181
F19939
J984
R0989
R52
T148
T68XXXA
T82519A
Z9981
F29
M549
R100
R55
T17300A
T699XXA
T887XXA
Z9989
G4489
O2690
R109
R569
T300
T7500XA
Y710
An emergency transport may be reimbursed by Texas Medicaid when it is submitted with modifier ET and one or
more of the emergency medical condition codes in the above table.
The requesting facility or physician must include with the claim, documentation that describes the client’s condition
which necessitated the ambulance transport. Medicaid recognizes limitations of usual ambulance personnel for
establishing a diagnosis, and recognizes that diagnosis coding of a client’s condition using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) when reporting ambulance transport services
may be less specific than for services reported by other professional providers.
Providers who submit ICD-10-CM diagnosis codes should choose the code that best describes the client’s condition
at the time of transport. Diagnoses that are “rule out” or “suspected” diagnoses should not be reported using
specific ICD-10-CM diagnosis codes. In such instances where a diagnosis is not confirmed, it is more correct to use
a symptom, finding, or injury diagnosis code.
Refer to: The Texas Medicaid Provider Procedures Manual, Ambulance Services Handbook, subsection 2.2.1
“Emergency Ambulance Transport Services,” for additional information.
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Ambulatory Blood Pressure Monitoring
Procedure codes 93784, 93786, 93788, and 93790 may be reimbursed when they are submitted with ICD-10-CM
diagnosis code R030, (submitted as a stand-alone diagnosis code).
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.26.1, “Ambulatory Blood Pressure Monitoring,” for additional information.
Ambulatory Electroencephalogram
Procedure codes 95950, 95951, 95953, and 95956 may be reimbursed when they are submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F05
F060
F068
G253
G3101
G3109
G3183
G40001
G40009
G40011
G40019
G40101
G40109
G40111
G40119
G40201
G40209
G40211
G40219
G40301
G40309
G40311
G40319
G40401
G40409
G40411
G40419
G40501
G40509
G40801
G40802
G40803
G40804
G40811
G40812
G40813
G40814
G4089
G40901
G40909
G40911
G40919
G40A11
G40A19
G40B01
G40B09
G40B11
G40B19
G912
O99351
O99352
O99353
O99354
O99355
P90
P912
R410
R4182
R5601
R561
R569
S060X1A
S060X1D
S060X1S
S060X2A
S060X2D
S060X2S
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.26.2, “Ambulatory Electroencephalogram (Ambulatory EEG),” for
additional information.
Ambulatory Surgical Center (ASC) and Hospital Ambulatory Surgical Center (HASC) Services
Incomplete surgical procedures may be reimbursed to ASC and HASC facilities when they are submitted with the
most appropriate diagnosis code or modifier as follows:
ICD-10-CM Diagnosis Codes
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z5309
Z5329
Z538
Modifiers
Modifier
73
74
Description
Discontinued outpatient procedure prior to anesthesia administration
Discontinued outpatient procedure after anesthesia administration
ASC and HASC facilities must use the most appropriate diagnosis code or modifier as identified above to indicate
that a surgical procedure was not completed. Claims billed with diagnosis codes Z5309, Z5329, Z538, or modifiers
73 or 74 will suspend for review of the medical documentation submitted with the claim. Providers are to submit
the operative report, the anesthesia report, and the reason the operation was not completed.
Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook,
subsection 4.2.3.6, “Incomplete Day Surgeries;” and subsection 5.2.2, “Incomplete Surgical Procedures,”
for additional information.
ICD-10 Special Bulletin, No. 8
10
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Anesthesia Reimbursement
Procedure code 99140 is not reimbursed for diagnosis codes O80 or O82 when one of these diagnoses is
documented as the referenced diagnosis on the claim. The referenced diagnosis must indicate the complicating
condition. Emergency is defined as existing when a delay in treatment of the client would lead to a significant
increase in the threat to life or body part.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.6.5, “Complicated Anesthesia;” and subsection 9.2.46, “Obstetrics
and Prenatal Care,” for additional information.
Bacillus Calmette-Guérin (BCG) Vaccine
Procedure code 90585 may be reimbursed when it is submitted with the ICD-10-CM diagnosis code Z23
(submitted as a stand-alone diagnosis code).
Procedure codes 90586 and J9031 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C670
C671
C672
C673
C674
C675
C7911
D090
C676
C677
C678
C679
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.9, “Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of
Bladder Cancer,” for additional information.
Blepharoplasty
Procedure codes 67901, 67902, 67903, 67904, 67906, and 67908 may be reimbursed for services rendered to clients
who are 21 years of age and older without prior authorization when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H0231
H0232
H0234
H02431
H02432
H02433
H0235
H02411
H02412
H02413
H02421
H02422
H02423
Procedure codes 67901, 67902, 67903, 67904, 67906, 67908, and 67909 may be reimbursed for services rendered
to clients who are 20 years of age and younger without prior authorization when they are submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Q100
Q101
Q102
Q103
Procedure codes 15820, 15821, 67911, 67961, 67966, 67971, 67973, 67974, and 67975 are not restricted to specific
diagnosis codes. The most appropriate, valid ICD-10 diagnosis code or codes must be submitted on the claim.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.13, “Blepharoplasty Procedures,” for additional information.
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Botulinum Toxin Type A and Type B
Botulinum toxin type A and type B procedure code J0585 may be reimbursed when submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes for J0585 (Submitted as stand-alone diagnosis codes)
G114
G2401
G241
G243
G244
G245
G248
G250
G251
G252
G253
G35
G360
G370
G371
G372
G374
G375
G378
G379
G43701 G43709 G43711 G43719 G800
G801
G802
G803
G804
G808
G809
G8110
G8111
G8112
G8113
G8114
G8220
G8221
G8222
G8250
G8251
G8252
G8253
G8254
G830
G8310
G8311
G8312
G8313
G8314
G8320
G8321
G8322
G8323
G8324
G8330
G8331
G8332
G8333
G8334
G834
H4901
H4902
H4903
H4911
H4912
H4913
H4921
H4922
H4923
H4931
H4932
H4933
H4941
H4942
H4943
H499
H5000
H50011 H50012
H50021 H50022 H50031 H50032 H50041 H50042 H5005
H5006
H5007
H5008
H5010
H50111
H50112 H50121 H50122 H50131 H50132 H50141 H50142 H5015
H5016
H5017
H5018
H5021
H5022
H5034
H5040
H5030
H50311 H50312
H5032
H50331 H50332 H50411 H50412 H5042
H5043
H5050
H5051
H5052
H5053
H5054
H5055
H5060
H50611 H50612 H5069
H50811 H50812 H5089
H510
H5111
H5112
H5121
H5122
H5123
H518
H519
I69031
I69032
I69033
I69034
I69041
I69042
I69043
I69044
I69051
I69052
I69053
I69054
I69061
I69062
I69063
I69064
I69065
I69098
I69131
I69132
I69133
I69134
I69141
I69142
I69143
I69144
I69151
I69152
I69153
I69154
I69161
I69162
I69163
I69164
I69165
I69198
I69231
I69232
I69233
I69234
I69241
I69242
I69243
I69244
I69251
I69252
I69253
I69254
I69261
I69262
I69263
I69264
I69265
I69298
I69331
I69332
I69333
I69334
I69341
I69342
I69343
I69344
I69351
I69352
I69353
I69354
I69361
I69362
I69363
I69364
I69365
I69398
I69831
I69832
I69833
I69834
I69841
I69842
I69843
I69844
I69851
I69852
I69853
I69854
I69861
I69862
I69863
I69864
I69865
I69898
J385
K117
K220
K600
K601
K602
M436
M62838 N3281
M722
N318
R490
R498
Procedure code J0586 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes for J0586 (Submitted as stand-alone diagnosis codes)
G114
G241
G243
G244
G245
G248
G35
G360
G370
G371
G372
G374
G375
G378
G379
G800
G801
G802
G804
G808
G809
G8110
G8111
G8112
G8113
G8114
J385
M436
M62838 M722
Procedure code J0587 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes for J0587 (Submitted as stand-alone diagnosis codes)
G243
K117
ICD-10 Special Bulletin, No. 8
12
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure code J0588 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes for J0588 (Submitted as stand-alone diagnosis codes)
G243
G245
G8110
G8111
G8112
G8113
G8114
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39.8, “Botulinum Toxin Type A and Type B,” for additional information.
Cardiac Rehabilitation
Procedure codes 93797, 93798, and S9472 and revenue code B943 may be reimbursed when they are submitted
with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I110
I201
I208
I209
I2101
I2102
I2109
I2111
I2119
I2121
I2129
I213
I214
I220
I221
I222
I228
I229
I501
I5020
I5022
I5023
I5030
I5031
I5032
I5033
I5040
I5041
I5042
I5021
Z9861
Z954
Z955
Z952
Z953
Z951
Z941
Z943
I5043
I509
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.19, “Cardiac Rehabilitation;” and the Inpatient and Outpatient
Hospital Services Handbook, subsection 4.2.6, “Cardiac Rehabilitation,” for additional information.
Chiropractic Manipulative Treatment (CMT)
CMT procedure codes may be reimbursed when they are submitted with diagnosis of subluxation of the spine. The
level of subluxation must be indicated by using one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M9900
M9901
M9902
M9903
M9904
M9905
M9908
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, Section 2.2, “Services, Benefits, Limitations, and Prior Authorization,”
for additional information.
Clubfoot Casting
Procedure codes 29450 and 29750 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M21541
M21542
M21549
Q660
Q661
Q662
Q663
Q664
Q6651
Q6652
Q666
Q667
Q6681
Q6682
Q6689
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.63.1, “Clubfoot Casting,” for additional information.
ICD-10 Special Bulletin, No. 8
13
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Colony Stimulating Factors
Procedure codes J1442, J2505 and J2820 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C000
C001
C002
C003
C004
C005
C006
C008
C01
C020
C021
C022
C023
C024
C028
C029
C030
C031
C039
C040
C041
C048
C049
C050
C051
C052
C059
C060
C061
C062
C0689
C069
C07
C080
C081
C089
C090
C091
C099
C100
C101
C102
C103
C104
C108
C109
C110
C111
C112
C113
C118
C119
C12
C130
C131
C132
C138
C139
C140
C142
C148
C153
C154
C155
C158
C159
C160
C161
C162
C163
C164
C165
C166
C168
C169
C170
C171
C172
C173
C178
C179
C180
C181
C182
C183
C184
C185
C186
C187
C188
C189
C19
C20
C210
C211
C218
C220
C221
C222
C223
C227
C228
C229
C23
C240
C241
C248
C249
C250
C251
C252
C253
C254
C257
C258
C259
C260
C261
C269
C300
C301
C310
C311
C312
C313
C318
C319
C320
C321
C322
C323
C328
C329
C33
C3401
C3402
C3411
C3412
C342
C3431
C3432
C3481
C3482
C3491
C3492
C37
C380
C381
C382
C383
C384
C388
C390
C399
C4001
C4002
C4011
C4012
C4021
C4022
C4031
C4032
C4081
C4082
C410
C411
C412
C413
C414
C430
C4311
C4312
C4321
C4322
C4331
C4339
C434
C4351
C4352
C4359
C4361
C4362
C4371
C4372
C438
C439
C460
C461
C463
C464
C4651
C4652
C467
C469
C478
C480
C481
C482
C488
C490
C4911
C4912
C4921
C4922
C493
C494
C495
C496
C498
C499
C4A0
C4A11
C4A12
C4A21
C4A22
C4A31
C4A39
C4A4
C4A51
C4A52
C4A59
C4A61
C4A62
C4A71
C4A72
C4A8
C50011
C50012
C50021
C50022
C50111
C50112
C50121
C50122
C50211
C50212
C50221
C50222
C50311
C50312
C50321
C50322
C50411
C50412
C50421
C50422
C50511
C50512
C50521
C50522
C50611
C50612
C50621
C50622
C50811
C50812
C50821
C50822
C50911
C50912
C50921
C50922
C510
C511
C512
C519
C52
C530
C531
C538
C539
C540
C541
C542
C543
C548
C55
C561
C562
C5701
C5702
C5711
C5712
C5721
C5722
C573
C574
C577
C578
C579
C58
C600
C601
C602
C608
C609
C61
C6201
C6202
C6211
C6212
C6291
C6292
C6301
C6302
C6311
C6312
C632
C637
C638
C639
C641
C642
C651
C652
C661
C662
C670
C671
C672
C673
C674
C675
C676
C677
C678
C679
C680
C681
C688
C689
C6901
C6902
C6911
C6912
C6921
C6922
C6931
C6932
C6951
C6952
C6961
C6962
C6981
C6982
C6991
C6992
C700
C701
C710
C711
C712
C713
C714
C715
C716
C717
C718
C719
C720
ICD-10 Special Bulletin, No. 8
14
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C721
C7221
C7222
C7231
C7232
C73
C7401
C7402
C7411
C7412
C754
C755
C758
C759
C760
C7642
C7651
C7652
C768
C770
C775
C778
C779
C7801
C7802
C785
C786
C787
C7889
C7901
C7931
C7949
C7951
C7952
C7961
C7982
C7989
C7A010
C7A011
C7A012
C7A024
C7A025
C7A026
C7A090
C7A091
C7A096
C7A098
C7A1
C7A8
C7B01
C7B1
C7B8
C800
C801
C802
C8105
C8106
C8107
C8108
C8109
C8115
C8116
C8117
C8118
C8119
C8125
C8126
C8127
C8128
C8129
C8135
C8136
C8137
C8138
C8139
C8145
C8146
C8147
C8148
C8149
C8175
C8176
C8177
C8178
C8179
C8195
C8196
C8197
C8198
C8199
C8205
C8206
C8207
C8208
C8209
C8215
C8216
C8217
C8218
C8219
C8225
C8226
C8227
C8228
C8229
C8235
C8236
C8237
C8238
C8239
C8245
C8246
C8247
C8248
C8249
C8255
C8256
C8257
C8258
C8259
C8265
C8266
C8267
C8268
C8269
C8285
C8286
C8287
C8288
C8289
C8295
C8296
C8297
C8298
C8299
C8305
C8306
C8307
C8308
C8309
C8315
C8316
C8317
C8318
C8319
C8335
C8336
C8337
C8338
C8339
C8355
C8356
C8357
C8358
C8359
C8375
C8376
C8377
C8378
C8379
C8385
C8386
C8387
C8388
C8389
C8395
C8396
C8397
C8398
C8399
C8405
C8406
C8408
C8409
C8411
C8416
C8417
C8418
C8419
C8441
C8446
C8447
C8448
C8449
C8461
C8466
C8467
C8468
C8469
C8471
C8476
C8477
C8478
C8479
C8491
C8496
C8497
C8498
C8499
C84A1
C84A6
C84A7
C84A8
C84A9
C84Z1
C84Z6
C84Z7
C84Z8
C84Z9
C8511
C8516
C8517
C8518
C8519
C8521
C8526
C8527
C8528
C8529
C8581
ICD-10 Special Bulletin, No. 8
15
C7241
C750
C761
C771
C781
C7902
C7962
C7A020
C7A092
C7B02
C8101
C8111
C8121
C8131
C8141
C8171
C8191
C8201
C8211
C8221
C8231
C8241
C8251
C8261
C8281
C8291
C8301
C8311
C8331
C8351
C8371
C8381
C8391
C8401
C8412
C8442
C8462
C8472
C8492
C84A2
C84Z2
C8512
C8522
C8582
C7242
C751
C762
C772
C782
C7911
C7971
C7A021
C7A093
C7B03
C8102
C8112
C8122
C8132
C8142
C8172
C8192
C8202
C8212
C8222
C8232
C8242
C8252
C8262
C8282
C8292
C8302
C8312
C8332
C8352
C8372
C8382
C8392
C8402
C8413
C8443
C8463
C8473
C8493
C84A3
C84Z3
C8513
C8523
C8583
C7259
C752
C763
C773
C7839
C7919
C7972
C7A022
C7A094
C7B04
C8103
C8113
C8123
C8133
C8143
C8173
C8193
C8203
C8213
C8223
C8233
C8243
C8253
C8263
C8283
C8293
C8303
C8313
C8333
C8353
C8373
C8383
C8393
C8403
C8414
C8444
C8464
C8474
C8494
C84A4
C84Z4
C8514
C8524
C8584
C729
C753
C7641
C774
C784
C792
C7981
C7A023
C7A095
C7B09
C8104
C8114
C8124
C8134
C8144
C8174
C8194
C8204
C8214
C8224
C8234
C8244
C8254
C8264
C8284
C8294
C8304
C8314
C8334
C8354
C8374
C8384
C8394
C8404
C8415
C8445
C8465
C8475
C8495
C84A5
C84Z5
C8515
C8525
C8585
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C8586
C8587
C8588
C8589
C8591
C8596
C8597
C8598
C8599
C860
C865
C866
C880
C882
C883
C9002
C9010
C9011
C9012
C9020
C9032
C9100
C9101
C9102
C9110
C9132
C9140
C9141
C9142
C9150
C9162
C91A0
C91A1
C91A2
C91Z0
C9202
C9210
C9211
C9212
C9220
C9232
C9240
C9241
C9242
C9250
C9262
C9290
C9291
C92Z0
C92Z1
C92A2
C9300
C9301
C9302
C9310
C9332
C93Z0
C93Z1
C93Z2
C9400
C9422
C9430
C9431
C9432
C9440
C9481
C9482
C9500
C9501
C9502
C9591
C9592
C960
C962
C964
D0001
D0002
D0003
D0004
D0005
D002
D010
D011
D012
D013
D021
D0221
D0222
D023
D030
D0339
D034
D0361
D0362
D0371
D0411
D0412
D0421
D0422
D0439
D0471
D0472
D048
D0501
D0502
D060
D061
D067
D070
D071
D0761
D0769
D090
D0919
D0921
D4981
D4989
D600
D601
D608
D6189
D700
D701
D702
D703
T451X1S
T451X2A T451X2D T451X2S T451X3A
T451X4S
T8601
T8602
T8603
T8609
Z9484
C8592
C861
C884
C9021
C9111
C9151
C91Z1
C9221
C9251
C92Z2
C9311
C9401
C9441
C9510
C965
D0006
D0149
D0311
D0372
D044
D0511
D072
D0922
D6109
D704
T451X3D
Z5111
C8593
C862
C888
C9022
C9112
C9152
C91Z2
C9222
C9252
C9292
C9312
C9402
C9442
C9511
C966
D0007
D015
D0312
D038
D045
D0512
D0739
D093
D611
P615
T451X3S
Z5112
C8594
C863
C9000
C9030
C9130
C9160
C9200
C9230
C9260
C92A0
C9330
C9420
C946
C9512
C96A
D0008
D017
D0321
D039
D0461
D0581
D074
D098
D612
T451X1A
T451X4A
Z5189
C8595
C864
C9001
C9031
C9131
C9161
C9201
C9231
C9261
C92A1
C9331
C9421
C9480
C9590
C96Z
D001
D020
D0322
D040
D0462
D0582
D075
D45
D613
T451X1D
T451X4D
Z9481
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39.12, “Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and
Sargramostim),” for additional information.
Colorectal Cancer Screening
Procedure codes G0104 and G0106 may be reimbursed once every five years as recommended by the ACS and
US Preventive Services Task Force (USPSTF) when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z0000*
Z0001*
Z1210
Z1211
Z1213
Z859
Z86010
*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more
frequently than recommended by the USPSTF.
Procedure code G0121 may be reimbursed once every ten years for patients who do not meet the criteria for
high-risk as recommended by the ACS and USPSTF. Procedure code G0121 must be submitted with one of the
following average risk ICD-10-CM diagnosis codes:
ICD-10 Special Bulletin, No. 8
16
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z0000*
Z0001*
Z1210
Z1211
Z1213
Z86010
*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more
frequently than recommended by the USPSTF.
Procedure codes G0105 and G0120 may be reimbursed once every two years for clients who meet the definition of
high-risk when they are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
K5000
K50011
K50012 K50013 K50014
K50018
K5010
K50111
K50112
K50113
K50114
K50118
K5080
K50811
K50812
K50813
K50814
K50818
K5090
K50911
K50912
K50913
K50914
K50918
K50919
K5120
K51211
K51212
K51213
K51214
K51218
K5130
K51311
K51312
K51313
K51314
K51318
K5180
K51811
K51812
K51813
K51814
K51818
K5190
K51911
K51912
K51913
K51914
K51918
K51919
K5281
K5282
K5289
K529
Z800
Z8371
Z85038 Z85048 Z859
Z86010
Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook,
subsection 4.2.8, “Colorectal Cancer Screening;” subsection 5.2.6, “Colorectal Cancer Screening;” and
the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.15.2,
“Colorectal Cancer Screening,” for additional information.
Cytogenetics Testing
Cytogenetics testing procedure codes may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C8280
C8281
C8282
C8283
C8284
C8289
C8291
C8292
C8293
C8294
C8299
C8310
C8311
C8312
C8313
C8318
C8319
C8380
C8381
C8382
C8387
C8388
C8389
C8440
C8441
C8446
C8447
C8448
C8449
C8461
C8466
C8467
C8468
C8469
C8471
C8476
C8477
C8478
C8479
C8581
C8587
C8588
C8589
C884
C888
C9110
C9111
C9112
C9190
C9191
C9200
C9201
C9202
C9210
C9211
C9230
C9231
C9232
C9240
C9241
C9260
C9261
C9262
C9290
C9291
C92Z0
C92Z1
C92Z2
C9300
C9301
C9330
C9331
C9390
C9391
C9392
C9401
C9402
C9420
C9421
C9422
C9481
C9482
C9500
C9501
C9502
C9591
C9592
D45
D821
E230
E8359
F70
F71
F72
F73
F804
F8089
F810
F812
F8181
F88
F900
F901
F902
F908
ICD-10 Special Bulletin, No. 8
17
C8285
C8295
C8314
C8383
C8442
C8462
C8472
C8582
C9012
C9192
C9212
C9242
C9292
C9302
C93Z0
C9430
C9510
E291
F78
F8189
H0589
C8286
C8296
C8315
C8384
C8443
C8463
C8473
C8584
C9100
C91Z0
C9220
C9250
C92A0
C9310
C93Z1
C9431
C9511
E300
F800
F819
H9325
C8287
C8297
C8316
C8385
C8444
C8464
C8474
C8585
C9101
C91Z1
C9221
C9251
C92A1
C9311
C93Z2
C9432
C9512
E343
F801
F82
I77810
C8288
C8298
C8317
C8386
C8445
C8465
C8475
C8586
C9102
C91Z2
C9222
C9252
C92A2
C9312
C9400
C9480
C9590
E83110
F802
F840
I77811
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I77812
I77819
M2600
M2601
M2602
M2607
M2609
N4601
N4611
N6482
N949
N970
N978
O010
O011
O09512
O09513
O09521
O09522
O09523
O350XX4 O350XX5 O350XX9 O351XX0 O351XX1
O351XX9 O352XX0 O352XX1 O352XX2 O352XX3
Q000
Q001
Q002
Q010
Q011
Q031
Q038
Q040
Q041
Q042
Q051
Q052
Q054
Q055
Q056
Q068
Q0701
Q0702
Q0703
Q078
Q103
Q104
Q106
Q107
Q110
Q121
Q123
Q124
Q128
Q129
Q134
Q135
Q1381
Q1389
Q140
Q150
Q158
Q159
Q160
Q161
Q169
Q170
Q171
Q172
Q173
Q180
Q181
Q182
Q183
Q184
Q189
Q200
Q201
Q202
Q203
Q209
Q210
Q211
Q212
Q213
Q221
Q222
Q223
Q224
Q225
Q233
Q234
Q238
Q240
Q241
Q246
Q248
Q249
Q250
Q251
Q259
Q260
Q261
Q262
Q263
Q270
Q271
Q272
Q2730
Q2731
Q278
Q279
Q280
Q281
Q282
Q301
Q302
Q303
Q308
Q309
Q315
Q318
Q320
Q321
Q322
Q332
Q333
Q334
Q335
Q336
Q351
Q353
Q359
Q360
Q369
Q374
Q375
Q380
Q381
Q382
Q387
Q388
Q391
Q392
Q393
Q400
Q401
Q402
Q408
Q409
Q420
Q421
Q422
Q423
Q428
Q434
Q435
Q437
Q438
Q440
Q445
Q446
Q447
Q450
Q451
Q5001
Q5002
Q501
Q502
Q5031
Q506
Q510
Q5110
Q5111
Q512
Q51821
Q51828
Q520
Q5210
Q522
Q5270
Q5271
Q5279
Q528
Q529
Q5311
Q5312
Q5320
Q5321
Q5322
Q543
Q544
Q548
Q550
Q551
Q553
Q554
Q555
Q5561
Q5562
Q559
Q560
Q561
Q562
Q563
Q604
Q606
Q6101
Q6119
Q612
Q619
Q6211
Q6212
Q622
Q6231
ICD-10 Special Bulletin, No. 8
18
M2603
N910
O019
O350XX0
O351XX2
O352XX4
Q012
Q045
Q057
Q079
Q111
Q130
Q141
Q162
Q174
Q185
Q204
Q214
Q228
Q242
Q252
Q265
Q2732
Q283
Q310
Q323
Q338
Q370
Q383
Q394
Q410
Q430
Q441
Q452
Q5032
Q515
Q523
Q5300
Q539
Q5521
Q5563
Q564
Q613
Q6239
M2604
N911
O021
O350XX1
O351XX3
O352XX5
Q018
Q046
Q058
Q100
Q112
Q131
Q142
Q163
Q175
Q186
Q205
Q218
Q230
Q243
Q253
Q266
Q2733
Q288
Q311
Q324
Q339
Q371
Q384
Q395
Q411
Q431
Q442
Q453
Q5039
Q516
Q524
Q5301
Q540
Q5522
Q5564
Q600
Q614
Q624
M2605
N913
O0289
O350XX2
O351XX4
O352XX9
Q02
Q048
Q062
Q101
Q113
Q132
Q143
Q164
Q178
Q187
Q206
Q219
Q231
Q244
Q254
Q268
Q2734
Q289
Q312
Q330
Q348
Q372
Q385
Q396
Q412
Q432
Q443
Q458
Q504
Q517
Q525
Q5302
Q541
Q5523
Q5569
Q601
Q615
Q625
M2606
N914
O09511
O350XX3
O351XX5
P293
Q030
Q050
Q064
Q102
Q120
Q133
Q148
Q165
Q179
Q188
Q208
Q220
Q232
Q245
Q2572
Q269
Q274
Q300
Q313
Q331
Q349
Q373
Q386
Q398
Q419
Q433
Q444
Q459
Q505
Q51811
Q526
Q5310
Q542
Q5529
Q558
Q603
Q618
Q6261
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Q6262
Q6263
Q628
Q630
Q631
Q6410
Q6411
Q6412
Q6419
Q642
Q644
Q645
Q646
Q6471
Q6472
Q6501
Q6502
Q651
Q6531
Q6532
Q660
Q662
Q663
Q664
Q6651
Q6682
Q6689
Q670
Q671
Q672
Q677
Q678
Q680
Q681
Q682
Q691
Q692
Q699
Q7001
Q7002
Q7021
Q7022
Q7023
Q7031
Q7032
Q7103
Q7111
Q7112
Q7113
Q7131
Q7143
Q7151
Q7152
Q7153
Q7161
Q71813
Q71891
Q71892
Q71893
Q7191
Q7203
Q7211
Q7212
Q7213
Q7231
Q7243
Q7251
Q7252
Q7253
Q7261
Q7273
Q72811
Q72812
Q72813
Q72891
Q7293
Q730
Q731
Q738
Q740
Q750
Q751
Q752
Q753
Q754
Q761
Q762
Q763
Q76411
Q76412
Q76426
Q76427
Q76428
Q7649
Q765
Q771
Q772
Q774
Q775
Q776
Q783
Q784
Q788
Q789
Q790
Q7959
Q796
Q798
Q799
Q800
Q808
Q820
Q821
Q822
Q823
Q831
Q832
Q833
Q838
Q840
Q845
Q846
Q848
Q849
Q8503
Q871
Q87410
Q87418
Q8742
Q8743
Q893
Q894
Q897
Q898
Q899
Q910
Q911
Q912
Q913
Q914
Q921
Q922
Q925
Q9261
Q9262
Q932
Q933
Q934
Q935
Q937
Q952
Q958
Q960
Q961
Q962
Q970
Q971
Q972
Q973
Q978
Q986
Q987
Q988
Q990
Q991
Z31430
Z31438
Z315
Z36
Z810
Q632
Q6431
Q6473
Q654
Q6652
Q673
Q683
Q7003
Q7033
Q7132
Q7162
Q7192
Q7232
Q7262
Q72892
Q742
Q755
Q76413
Q766
Q777
Q791
Q801
Q824
Q841
Q851
Q8901
Q900
Q915
Q927
Q9381
Q963
Q980
Q992
Z8279
Q633
Q6432
Q6474
Q6581
Q666
Q674
Q684
Q7011
Q709
Q7133
Q7163
Q7193
Q7233
Q7263
Q72893
Q743
Q758
Q76414
Q767
Q780
Q792
Q802
Q825
Q842
Q858
Q8909
Q901
Q916
Q928
Q9388
Q964
Q981
Q998
Z8489
Q638
Q6433
Q6475
Q6582
Q667
Q675
Q688
Q7012
Q7101
Q7141
Q71811
Q7201
Q7241
Q7271
Q7291
Q748
Q759
Q76415
Q768
Q781
Q793
Q803
Q828
Q843
Q859
Q891
Q902
Q917
Q930
Q9389
Q968
Q984
Q999
Q640
Q6439
Q649
Q6589
Q6681
Q676
Q690
Q7013
Q7102
Q7142
Q71812
Q7202
Q7242
Q7272
Q7292
Q749
Q760
Q76425
Q770
Q782
Q794
Q804
Q830
Q844
Q870
Q892
Q909
Q920
Q931
Q950
Q969
Q985
R480
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
Q6501
Q6502
Q6532
Q6531
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
ICD-10 Special Bulletin, No. 8
19
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.41.6, “Cytogenetics Testing,” for additional information.
Developmental and Neurological Assessment and Testing
Medically necessary assessment of aphasia procedure code 96105 may be reimbursed when it is submitted with one
of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R4701
R471
R4702
R4781
R4789
Neurobehavioral examination procedure code 96116 may be reimbursed when one of the following ICD-10-CM
medical or psychiatric diagnoses exists that establishes the need for a detailed evaluation of neurological impairment:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A8100
A8101
A8109
A8181
A8183
B451
D8681
E7500
E7501
E7502
E7523
E7525
E7529
E754
F0150
F0391
F04
F05
F060
F061
F0634
F064
F068
F070
F0633
F10121
F1014
F10150
F10180
F10181
F1024
F10250
F1026
F1027
F10280
F1094
F10950
F1096
F1097
F10980
F11121
F11150
F11151
F1120
F11220
F11251
F11920
F11921
F11929
F1193
F12121
F12129
F12150
F12151
F12220
F1290
F12920
F12921
F12929
F12950
F13129
F13150
F13151
F13220
F13221
F13239
F13250
F13251
F13920
F13921
F13939
F13950
F13951
F1410
F14120
F14182
F14220
F14221
F14229
F1423
F14929
F14950
F14951
F1510
F15120
F15220
F15221
F15229
F1523
F15250
F1593
F15950
F15951
F1610
F16121
F16221
F16229
F16250
F16251
F16920
F17203
F17213
F17223
F17293
F1810
F18151
F18220
F18221
F18229
F18250
F18950
F18951
F1910
F19120
F19121
F19220
F19221
F19229
F19230
F19231
F1929
F19920
F19921
F19929
F19930
F19951
F1999
F200
F201
F202
F209
F21
F22
F23
F24
F28
F29
F3010
F3011
F3012
F308
F309
F3110
F3111
F3112
ICD-10 Special Bulletin, No. 8
20
A8189
E7509
F0151
F062
F0781
F10188
F10281
F10981
F11221
F11950
F12221
F12951
F13229
F13929
F14121
F14250
F15121
F15251
F16129
F16921
F18120
F18251
F19129
F19232
F19931
F203
F250
F3013
F3113
A819
E7510
F0280
F0630
F0789
F1019
F10288
F10988
F11229
F11951
F12229
F1310
F13230
F13930
F14129
F14251
F15129
F15920
F16150
F16929
F18121
F18920
F19150
F19239
F19932
F205
F251
F302
F312
B1001
E7511
F0281
F0631
F09
F1020
F1029
F1099
F1123
F1210
F12250
F13120
F13231
F13931
F14150
F14920
F15150
F15921
F16151
F16950
F18129
F18921
F19151
F19250
F19939
F2081
F258
F303
F3130
B1009
E7519
F0390
F0632
F1010
F10221
F10921
F1110
F11250
F12120
F12251
F13121
F13232
F13932
F14151
F14921
F15151
F15929
F16220
F16951
F18150
F18929
F1919
F19251
F19950
F2089
F259
F304
F3131
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F3132
F314
F315
F3160
F3161
F3173
F3174
F3175
F3176
F3177
F320
F321
F322
F323
F324
F331
F332
F333
F3341
F3342
F348
F349
F39
F4001
F4002
F40220
F40228
F40230
F40231
F40232
F40243
F40248
F40290
F40291
F40298
F413
F418
F419
F42
F430
F4321
F4322
F4323
F4324
F4325
F441
F442
F444
F445
F446
F450
F451
F4520
F4521
F4522
F459
F481
F482
F488
F489
F508
F509
F5101
F5102
F5103
F5112
F5113
F5119
F513
F514
F521
F5221
F5222
F5231
F5232
F529
F53
F600
F601
F602
F607
F6081
F6089
F609
F630
F6389
F639
F641
F642
F648
F653
F654
F6551
F6552
F6581
F6811
F6812
F6812
F6813
F688
F79
F801
F802
F804
F819
F845
F848
F849
F88
F89
F909
F910
F911
F912
F913
F939
F940
F941
F942
F948
F959
F980
F981
F9821
F9829
F989
G000
G001
G002
G003
G030
G031
G032
G038
G039
G0430
G0431
G0432
G0439
G0481
G054
G060
G061
G062
G07
G309
G3101
G3109
G311
G3181
G3289
G35
G40001
G40009
G40011
G40119
G40201
G40209
G40211
G40219
G40501
G40509
G40801
G40802
G40803
G40814
G40821
G40822
G40823
G40824
G40919
G40A01
G40A09
G40A11
G40A19
G450
G451
G452
G454
G458
G912
G92
G930
G931
G9340
G9389
G939
G94
H93291
H93292
I6010
I6011
I6012
I6020
I6021
ICD-10 Special Bulletin, No. 8
21
F3162
F3178
F325
F338
F4010
F40233
F408
F4310
F4329
F447
F4529
F5000
F5104
F515
F524
F603
F631
F649
F6589
F70
F82
F900
F918
F950
F983
G008
G0400
G0489
G210
G3182
G40019
G40301
G40804
G4089
G40B01
G459
G9341
H93293
I6022
F3163
F3181
F328
F339
F4011
F40240
F409
F4311
F438
F4481
F4541
F5001
F5105
F518
F525
F604
F632
F650
F659
F71
F840
F901
F919
F951
F984
G009
G0401
G0490
G300
G3183
G40101
G40309
G40811
G40901
G40B09
G468
G9349
I6000
I6030
F3164
F3189
F329
F340
F40210
F40241
F410
F4312
F439
F4489
F4542
F5002
F5109
F519
F526
F605
F633
F651
F66
F72
F842
F902
F930
F952
F985
G01
G0402
G0491
G301
G3185
G40109
G40311
G40812
G40909
G40B11
G910
G937
I6001
I6031
F3170
F319
F330
F341
F40218
F40242
F411
F4320
F440
F449
F458
F502
F5111
F520
F528
F606
F6381
F652
F6810
F73
F843
F908
F938
F958
F988
G02
G042
G053
G308
G319
G40111
G40319
G40813
G40911
G40B19
G911
G9381
I6002
I6032
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I604
I6050
I6051
I6052
I606
I611
I612
I613
I614
I615
I6201
I6202
I6203
I621
I629
I6302
I63031
I63032
I63039
I6309
I6312
I63131
I63132
I63139
I6319
I6322
I63231
I63232
I63239
I6329
I63321
I63322
I63329
I63331
I63332
I6339
I6340
I63411
I63412
I63419
I63432
I63439
I63441
I63442
I63449
I63519
I63521
I63522
I63529
I63531
I63549
I6359
I6501
I6502
I6503
I6523
I6529
I658
I659
I6601
I6612
I6613
I6619
I6621
I6622
I669
I671
I672
I674
I675
I6789
I679
I680
I682
I688
I69022
I69023
I69028
I69031
I69032
I69042
I69043
I69044
I69049
I69051
I69061
I69062
I69063
I69064
I69065
I69093
I69098
I6910
I6911
I69120
I69131
I69132
I69133
I69134
I69139
I69149
I69151
I69152
I69153
I69154
I69164
I69165
I69169
I69190
I69191
I6921
I69220
I69221
I69222
I69223
I69234
I69239
I69241
I69242
I69243
I69253
I69254
I69259
I69261
I69262
I69290
I69291
I69292
I69293
I69298
I69322
I69323
I69328
I69331
I69332
I69342
I69343
I69344
I69349
I69351
I69361
I69362
I69363
I69364
I69365
I69393
I69398
I6980
I6981
I69820
I69831
I69832
I69833
I69834
I69839
I69849
I69851
I69852
I69853
I69854
I69864
I69865
I69869
I69890
I69891
I6991
I69920
I69921
I69922
I69923
I69934
I69939
I69941
I69942
I69943
I69953
I69954
I69959
I69961
I69962
I69990
I69991
I69992
I69993
I69998
P5221
P5222
P523
P525
P84
P9163
R0901
R0902
R37
R41840
ICD-10 Special Bulletin, No. 8
22
I607
I616
I6300
I6310
I6320
I6330
I63339
I63421
I6349
I63532
I6509
I6602
I6623
I676
I6900
I69033
I69052
I69069
I69121
I69141
I69159
I69192
I69228
I69244
I69263
I6930
I69333
I69352
I69369
I69821
I69841
I69859
I69892
I69928
I69944
I69963
P102
P90
R41841
I608
I618
I63011
I63111
I63211
I63311
I63341
I63422
I6350
I63539
I651
I6603
I6629
I677
I6901
I69034
I69053
I69090
I69122
I69142
I69161
I69193
I69231
I69249
I69264
I6931
I69334
I69353
I69390
I69822
I69842
I69861
I69893
I69931
I69949
I69964
P103
P9160
R41842
I609
I619
I63012
I63112
I63212
I63312
I63342
I63429
I63511
I63541
I6521
I6609
I663
I6781
I69020
I69039
I69054
I69091
I69123
I69143
I69162
I69198
I69232
I69251
I69265
I69320
I69339
I69354
I69391
I69823
I69843
I69862
I69898
I69932
I69951
I69965
P520
P9161
R41843
I610
I6200
I63019
I63119
I63219
I63319
I63349
I63431
I63512
I63542
I6522
I6611
I668
I6782
I69021
I69041
I69059
I69092
I69128
I69144
I69163
I6920
I69233
I69252
I69269
I69321
I69341
I69359
I69392
I69828
I69844
I69863
I6990
I69933
I69952
I69969
P521
P9162
R41844
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R4189
R450
R453
R454
R45850
R45851
R5600
R569
S060X0A
S060X0D S060X0S S060X1A
S060X2D S060X2S S060X3A S060X4A S060X5A S060X5D
S060X6S S060X9A S060X9D S060X9S S06306D S06306S
S06311A
S06311D S06311S
S06312A
S06312D S06312S
S06314A
S06314D S06314S
S06315A
S06315D S06315S
S06319A
S06319D S06319S
S06320A
S06320D S06320S
S06322A S06322D S06322S
S06323A
S06323D S06323S
S06325A
S06325D S06325S
S06326A S06326D S06326S
S06330A
S06330D S06330S
S06331A
S06331D S06331S
S06333A
S06333D S06333S
S06334A S06334D S06334S
S06336A S06336D S06336S
S06339A
S06339D S06339S
S06341A
S06341D S06341S
S06342A S06342D S06342S
S06344A S06344D S06344S
S06345A
S06345D S06345S
S06349A
S06349D S06349S
S06350A
S06350S
S06351A
S06352D S06352S
S06353A
S06353D S06353S
S06354A
S06355D S06355S
S06356A
S06356D S06356S
S06359A
S06361A
S06361D S06361S
S06362A S06362D S06362S
S06364A S06364D S06364S
S06365A
S06365D S06365S
S06369A
S06369D S06369S
S06370A
S06370D S06370S
S06372A S06372D S06372S
S06373A
S06373D S06373S
S06375A
S06375D S06375S
S06376A
S06376D S06376S
S06380A S06380D S06380S
S06381A
S06381D S06381S
S06383A
S06383D S06383S
S06384A S06384D S06384S
S06386A S06386D S06386S
S06389A
S06389D S06389S
S064X1A S064X1D S064X1S
S064X2A S064X2D S064X2S
S064X4A S064X4D S064X4S
S064X5A S064X5D S064X5S
S064X9A S064X9D S064X9S
S065X0A S065X0D S065X0S
S065X2A S065X2D S065X2S
S065X3A S065X3D S065X3S
S065X5A S065X5D S065X5S
S065X6A S065X6D S065X6S
S065X9D S065X9S S066X0A S066X0D S066X0S S066X1A
S066X2D S066X2S S066X3A S066X3D S066X3S S066X4A
S066X5D S066X5S S066X6A S066X6D S066X6S S066X9A
S06890D S06890S
S06891A
S06891D S06891S
S06892A
S06893D S06893S
S06894A
S06894D S06894S
S06895A
S06896D S06896S
S06897S
S06899A
S06899D S06899S
S069X1A S069X1D S069X1S
S069X2A S069X2D S069X2S
S069X4A S069X4D S069X4S
S069X5A S069X5D S069X5S
S069X9A S069X9D S069X9S
T5801XA T5801XD T5801XS
ICD-10 Special Bulletin, No. 8
23
R4586
S060X1D
S060X5S
S06310A
S06313A
S06316A
S06321A
S06324A
S06329A
S06332A
S06335A
S06340A
S06343A
S06346A
S06351D
S06354D
S06360A
S06363A
S06366A
S06371A
S06374A
S06379A
S06382A
S06385A
S064X0A
S064X3A
S064X6A
S065X1A
S065X4A
S065X7A
S066X1D
S066X4D
S066X9D
S06892D
S06895D
S069X0A
S069X3A
S069X6A
T5802XA
R4587
R4589
S060X1S S060X2A
S060X6A S060X6D
S06310D S06310S
S06313D S06313S
S06316D S06316S
S06321D S06321S
S06324D S06324S
S06329D S06329S
S06332D S06332S
S06335D S06335S
S06340D S06340S
S06343D S06343S
S06346D S06346S
S06351S
S06352A
S06354S
S06355A
S06360D S06360S
S06363D S06363S
S06366D S06366S
S06371D S06371S
S06374D S06374S
S06379D S06379S
S06382D S06382S
S06385D S06385S
S064X0D S064X0S
S064X3D S064X3S
S064X6D S064X6S
S065X1D S065X1S
S065X4D S065X4S
S065X8A S065X9A
S066X1S S066X2A
S066X4S S066X5A
S066X9S S06890A
S06892S
S06893A
S06895S
S06896A
S069X0D S069X0S
S069X3D S069X3S
S069X6D S069X6S
T5802XD T5803XA
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T5803XD T5804XA T5804XD T5804XS T5811XA
T5813XA T5813XD T5814XA T5814XD T5814XS
T582X2D T582X3A T582X3D T582X4A T582X4D
T588X2D T588X3A T588X3D T588X3S T588X4A
T5891XS T5892XA T5892XD T5893XA T5893XD
T71111S
T71112A T71112S
T71113A
T71113D
T71121A T71121D T71121S
T71122A T71122S
T71124S
T71131A T71131D
T71131S
T71132A
T71134D T71134S
T71141A
T71141D T71141S
T71144D T71144S
T71151A
T71151D T71151S
T71153D T71153S
T71154A
T71154D T71154S
T71191A
T71192A T71193A
T71194A T71194D
T71222A T71223A T71224A T71231A T71232A
T719XXA T751XXA T751XXD T751XXS Z134
Z658
Z69021
Z6982
Z72810
Z72811
Z818
Z8651
Z8659
Z87820
Z87890
T5811XD
T582X1A
T588X1A
T588X4D
T5894XA
T71113S
T71123A
T71133A
T71143A
T71152A
T71161A
T71194S
T71233A
Z13850
Z73810
T5811XS
T582X1D
T588X1D
T588X4S
T5894XD
T71114A
T71123D
T71133D
T71143D
T71152D
T71162A
T7120XA
T71233D
Z13858
Z73811
T5812XA
T582X1S
T588X1S
T5891XA
T71111A
T71114D
T71123S
T71133S
T71143S
T71152S
T71163A
T7121XA
T71234A
Z1389
Z73812
T5812XD
T582X2A
T588X2A
T5891XD
T71111D
T71114S
T71124A
T71134A
T71144A
T71153A
T71164A
T71221A
T7129XA
Z634
Z73819
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
F0390,
S0190XA,
S0190XA,
S0190XA,
F05
S06330A
S06331A
S06332A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06336A
S06339A
S06330A
S06332A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06335A
S06336A
S06339A
S06370A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06381A
S06371A
S06383A
S06384A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06385A
S06386A
S06376A
S06386A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06370A
S06380A
S06382A
S06371A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06374A
S06373A
S06384A
S06383A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06379A
S06389A
S06330A
S06331A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06335A
S06336A
S06339A
S066X0A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S066X5A
S066X6A
S066X9A
S065X0A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S065X3A
S065X4A
S065X3A
S065X5A
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S064X1A
S064X2A
S064X4A
S064X3A
ICD-10 Special Bulletin, No. 8
24
S0190XA,
S06334A
S0190XA,
S06331A
S0190XA,
S06380A
S0190XA,
S06373A
S0190XA,
S06376A
S0190XA,
S06372A
S0190XA,
S06373A
S0190XA,
S06332A
S0190XA,
S066X1A
S0190XA,
S065X1A
S0190XA,
S065X6A
S0190XA,
S064X5A
S0190XA,
S06333A
S0190XA,
S06334A
S0190XA,
S06372A
S0190XA,
S06374A
S0190XA,
S06389A
S0190XA,
S06381A
S0190XA,
S06376A
S0190XA,
S06334A
S0190XA,
S066X2A
S0190XA,
S065X2A
S0190XA,
S065X9A
S0190XA,
S064X6A
S0190XA,
S06335A
S0190XA,
S06333A
S0190XA,
S06382A
S0190XA,
S06375A
S0190XA,
S06379A
S0190XA,
S06383A
S0190XA,
S06386A
S0190XA,
S06333A
S0190XA,
S066X3A
S0190XA,
S065X4A
S0190XA,
S064X0A
S0190XA,
S064X9A
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Combination Diagnosis Codes (Must be submitted in pairs)
S0190XA,
S0190XA,
S0190XA,
S0190XA,
S06360A
S06361A
S06362A
S06364A
S0190XA,
S060X0A,
S0190XD,
S0190XD,
S06369A
S06890A
S06330D
S06331D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06335D
S06336D
S06339D
S06330D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06333D
S06335D
S06336D
S06339D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06382D
S06381D
S06371D
S06383D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06375D
S06385D
S06386D
S06376D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06379D
S06370D
S06380D
S06382D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06383D
S06374D
S06373D
S06384D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06386D
S06379D
S06389D
S06330D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S06333D
S06335D
S06336D
S06339D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S066X3D
S066X5D
S066X6D
S066X9D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S065X4D
S065X3D
S065X4D
S065X3D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S064X0D
S064X1D
S064X2D
S064X4D
S0190XD,
S0190XD,
S0190XD,
S0190XD,
S064X9D
S06360D
S06361D
S06362D
S0190XD,
S0190XD,
S060X0D,
S0190XS,
S06366D
S06369D
S06890D
S06330S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06333S
S06335S
S06336S
S06339S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06334S
S06333S
S06335S
S06336S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06372S
S06382S
S06381S
S06371S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06374S
S06375S
S06385S
S06386S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06389S
S06379S
S06370S
S06380S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06381S
S06383S
S06374S
S06373S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06376S
S06386S
S06379S
S06389S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S06334S
S06333S
S06335S
S06336S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S066X2S
S066X3S
S066X5S
S066X6S
ICD-10 Special Bulletin, No. 8
25
S0190XA,
S06363A
S0190XD,
S06332D
S0190XD,
S06332D
S0190XD,
S06370D
S0190XD,
S06384D
S0190XD,
S06386D
S0190XD,
S06371D
S0190XD,
S06383D
S0190XD,
S06331D
S0190XD,
S066X0D
S0190XD,
S065X0D
S0190XD,
S065X5D
S0190XD,
S064X3D
S0190XD,
S06364D
S0190XS,
S06331S
S0190XS,
S06330S
S0190XS,
S06339S
S0190XS,
S06383S
S0190XS,
S06376S
S0190XS,
S06382S
S0190XS,
S06384S
S0190XS,
S06330S
S0190XS,
S06339S
S0190XS,
S066X9S
S0190XA,
S06365A
S0190XD,
S06334D
S0190XD,
S06331D
S0190XD,
S06380D
S0190XD,
S06373D
S0190XD,
S06376D
S0190XD,
S06372D
S0190XD,
S06373D
S0190XD,
S06332D
S0190XD,
S066X1D
S0190XD,
S065X1D
S0190XD,
S065X6D
S0190XD,
S064X5D
S0190XD,
S06363D
S0190XS,
S06332S
S0190XS,
S06332S
S0190XS,
S06370S
S0190XS,
S06384S
S0190XS,
S06386S
S0190XS,
S06371S
S0190XS,
S06383S
S0190XS,
S06331S
S0190XS,
S066X0S
S0190XS,
S065X0S
S0190XA,
S06366A
S0190XD,
S06333D
S0190XD,
S06334D
S0190XD,
S06372D
S0190XD,
S06374D
S0190XD,
S06389D
S0190XD,
S06381D
S0190XD,
S06376D
S0190XD,
S06334D
S0190XD,
S066X2D
S0190XD,
S065X2D
S0190XD,
S065X9D
S0190XD,
S064X6D
S0190XD,
S06365D
S0190XS,
S06334S
S0190XS,
S06331S
S0190XS,
S06380S
S0190XS,
S06373S
S0190XS,
S06376S
S0190XS,
S06372S
S0190XS,
S06373S
S0190XS,
S06332S
S0190XS,
S066X1S
S0190XS,
S065X1S
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Combination Diagnosis Codes (Must be submitted in pairs)
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S065X2S
S065X4S
S065X3S
S065X4S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S065X9S
S064X0S
S064X1S
S064X2S
S0190XS,
S0190XS,
S0190XS,
S0190XS,
S064X6S
S064X9S
S06360S
S06361S
S0190XS,
S0190XS,
S0190XS,
S060X0S,
S06365S
S06366S
S06369S
S06890S
S0190XS,
S065X3S
S0190XS,
S064X4S
S0190XS,
S06362S
S0190XS,
S065X5S
S0190XS,
S064X3S
S0190XS,
S06364S
S0190XS,
S065X6S
S0190XS,
S064X5S
S0190XS,
S06363S
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Retrospective review may be performed for all evaluation and management (E/M) procedure codes, including those
listed in the Evaluation and Management Section of the Current Procedural Terminology (CPT) Manual, when
they are billed with one of the diagnosis codes listed in the above tables for procedure code 96116.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.25, “Developmental and Neurological Assessment and Testing;”
subsection 9.2.25.1, “Assessment of Aphasia;” and subsection 9.2.25.4, “Neurobehavioral Testing” for
additional information.
Diagnostic Doppler Sonography
Diagnostic Doppler sonography procedure codes must be submitted with the most appropriate ICD-10-CM
diagnosis codes as indicated in this article. Extracranial arterial Doppler procedure codes 93880 and 93882 may be
reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D446
D447
D7801
D7802
D7811
E3601
E3602
E3611
E3612
G450
G459
G8100
G8101
G8102
G8103
G8112
G8113
G8114
G8190
G8191
G9731
G9732
G9748
G9749
G9751
H3403
H3411
H3412
H3413
H34211
H34232
H34233
H34811
H34812
H34813
H34831
H34832
H34833
H349
H3582
H53123
H53131
H53132
H53133
H532
H53413
H53421
H53422
H53423
H53431
H53452
H53453
H53461
H53462
H5347
H59111
H59112
H59113
H59119
H59121
D7812
G453
G8104
G8192
G9752
H34212
H34821
H5310
H5340
H53432
H53481
H59122
D7821
G454
G8110
G8193
H3401
H34213
H34822
H53121
H53411
H53433
H53482
H59123
D7822
G458
G8111
G8194
H3402
H34231
H34823
H53122
H53412
H53451
H53483
H59129
* Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, ** Use R220 or R221 to report pulsatile
neck mass, *** Use R0989 to report carotid bruit
ICD-10 Special Bulletin, No. 8
26
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H59211
H59212
H59213
H59219
H59221
H59311
H59312
H59313
H59319
H59321
H9521
H9522
H9531
H9532
H9541
I612
I613
I614
I615
I616
I63011
I63012
I6302
I63031
I63032
I63112
I6312
I63131
I63132
I6319
I63312
I63321
I63322
I63331
I63332
I63422
I63431
I63432
I63511
I63512
I63532
I6359
I638
I6501
I6502
I6522
I6523
I658
I659
I6601
I6611
I6612
I6613
I6619
I6621
I669
I671
I672
I677
I6781
I679
I680
I682
I6990
I69920
I69961
I69962
I69963
I69964
I69965
I69992
I69993
I7100
I720
I728
I773
I776
I7789
I779
I97410
I9751
I9752
I97610
I97611
I97618
J9571
J9572
J95830
J95831
K9161
K91840
K91841
L7601
L7602
L7611
M300
M303
M310
M311
M312
M315
M316
M96810
M96811
M96820
N9961
N9962
N9971
N9972
N99820
R201
R202
R203
R208
R209
R261
R2681
R2689
R269
R270
R4701
R4702
R471
R4781
R4789
S090XXA
S090XXD
S090XXS
S15001A
S15001D
S15009D
S15011A
S15011D
S15012A
S15012D
S15022D
S15091A
S15091D
S15092A
S15092D
S15212D
S15221A
S15221D
S15222A
S15222D
S15292D
S15311A
S15311D
S15312A
S15312D
S15322D
S15391A
S15391D
S15392A
S15392D
S159XXD
S159XXS
S178XXA
S178XXD
S25111A
S25121A
S25121D
S25122A
S25122D
S25191A
T794XXA T794XXD T8030XA
T8030XD
T8030XS
T80311A
T80311D
T80311S
T80319A
T80319D
T8039XS
T8040XA
T8040XD
T8040XS
T80410A
T80411D
T80411S
T80419A
T80419D
T80419S
H59222
H59322
H9542
I618
I6309
I6320
I63411
I63521
I6503
I6602
I6622
I6782
I69921
I69969
I770
I97411
I9762
K9162
L7612
M3130
M96821
N99821
R220**
R278
R5084
S15002A
S15021A
S15211A
S15291A
S15321A
S158XXA
S25111D
S25191D
T80310A
T80319S
T80410D
T8049XA
H59223
H59323
I610
I619
I6310
I6329
I63412
I63522
I651
I6603
I6623
I67848
I69922
I69990
I771
I97418
J9561
K9171
L7621
M3131
M96830
R0989***
R221**
R279
R55*
S15002D
S15021D
S15211D
S15291D
S15321D
S158XXD
S25112A
S25192A
T80310D
T8039XA
T80410S
T80910A
H59229
H59329
I611
I6300
I63111
I63311
I63421
I63531
I6521
I6609
I663
I6789
I69923
I69991
I772
I9742
J9562
K9172
L7622
M314
M96831
R200
R260
R295
R561
S15009A
S15022A
S15212A
S15292A
S15322A
S159XXA
S25112D
S25192D
T80310S
T8039XD
T80411A
T80910D
* Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, ** Use R220 or R221 to report pulsatile
neck mass, *** Use R0989 to report carotid bruit
ICD-10 Special Bulletin, No. 8
27
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T80910S
T80911A
T80911D
T80911S
T80919A
T80A10A
T80A10D
T80A10S
T80A11A
T80A11D
T80A19S
T80A9XA
T80A9XD T80A9XS
T8130XA
T8131XS
T8132XA
T8132XD
T8132XS
T8133XA
T81500D
T81500S
T81501A
T81501D
T81501S
T81503A
T81503D
T81503S
T81504A
T81505A
T81506D
T81506S
T81507A
T81507D
T81507S
T81509A
T81510A
T81510D
T81510S
T81511A
T81512D
T81512S
T81513A
T81513D
T81513S
T81515S
T81516A
T81516D
T81516S
T81517A
T81518D
T81518S
T81519A
T81520A
T81520D
T81521S
T81522A
T81522D
T81522S
T81523A
T81525A
T81525D
T81525S
T81526A
T81526D
T81527S
T81528A
T81528D
T81528S
T81529A
T81531A
T81532A
T81533A
T81534A
T81535A
T81539A
T81590A
T81591A
T81592A
T81593A
T81597A
T81598A
T81599A
T8160XA
T8160XD
T8169XD
T8169XS
T8183XA
T8183XD
T8183XS
T82391A
T82391D
T82391S
T82392A
T82392D
T8249XS
T82590A
T82590D
T82590S
T82591A
T82593D
T82593S
T82595A
T82595D
T82595S
T888XXA
T888XXD T888XXS
Z09
Z95820
Z9862
Z9889
T80A0XA
T80A11S
T8130XD
T8133XD
T81502A
T81505D
T81508A
T81511D
T81514A
T81517D
T81520S
T81523D
T81526S
T81530A
T81536A
T81594A
T8160XS
T82390A
T82392S
T82591D
T82598A
Z95828
T80A0XD
T80A19A
T8131XA
T8133XS
T81502D
T81505S
T81508D
T81511S
T81515A
T81517S
T81521A
T81523S
T81527A
T81530D
T81537A
T81595A
T8161XA
T82390D
T8249XA
T82591S
T82598D
Z978
T80A0XS
T80A19D
T8131XD
T81500A
T81502S
T81506A
T81508S
T81512A
T81515D
T81518A
T81521D
T81524A
T81527D
T81530S
T81538A
T81596A
T8169XA
T82390S
T8249XD
T82593A
T82598S
Z983
* Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, ** Use R220 or R221 to report pulsatile
neck mass, *** Use R0989 to report carotid bruit
Transcranial Doppler procedure codes 93886, 93888, 93890, 93892, and 93893 may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D7801
D7802
D7811
D7812
D7821
E3611
E3612
G450
G453
G454
G8101
G8102
G8103
G8104
G8110
G8114
G8190
G8191
G8192
G8193
G8222
G8250
G8251
G8252
G8253
G8311
G8312
G8313
G8314
G8320
G8324
G8330
G8331
G8332
G8333
G9382
G9389*
G9731
G9732
G9748
H3401
H3402
H3403
H3411
H3412
D7822
G458
G8111
G8194
G8254
G8321
G8334
G9749
H3413
E3601
G459
G8112
G8220
G830
G8322
G839
G9751
H34211
E3602
G8100
G8113
G8221
G8310
G8323
G9381
G9752
H34212
* Use G9389 to identify assessment of suspected brain death, ** Use I749 to report paradoXical cerebral embolism, *** Use R55 when
symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, **** Use R0989 to report carotid bruit
ICD-10 Special Bulletin, No. 8
28
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H34213
H34231
H34232
H34233
H34811
H34822
H34823
H34831
H34832
H34833
H4902
H4903
H4911
H4912
H4913
H4931
H4932
H4933
H4941
H4942
H52512
H52513
H5310
H53121
H53122
H53133
H532
H5340
H53411
H53412
H53423
H53431
H53432
H53433
H53451
H53462
H5347
H53481
H53482
H53483
H59119
H59121
H59122
H59123
H59129
H59219
H59221
H59222
H59223
H59229
H59319
H59321
H59322
H59323
H59329
H9532
H9541
H9542
I6000
I6001
I6012
I6020
I6021
I6022
I6030
I6050
I6051
I6052
I606
I607
I611
I612
I613
I614
I615
I6300
I63011
I63012
I6302
I63031
I63111
I63112
I6312
I63131
I63132
I63311
I63312
I63321
I63322
I63331
I63421
I63422
I63431
I63432
I63511
I63531
I63532
I638
I6501
I6502
I6522
I6523
I658
I659
I6601
I6611
I6612
I6613
I6619
I6621
I669
I671
I672
I675
I677
I6789
I679
I680
I682
I69098
I69922
I69923
I69961
I69962
I69963
I69990
I69991
I69992
I69993
I7090
I749**
I770
I771
I772
I773
I97410
I97411
I97418
I9742
I9751
I97618
I9762
J9561
J9562
J9571
K9161
K9162
K9171
K9172
K91840
L7611
L7612
L7621
L7622
M300
M312
M3130
M3131
M314
M315
M96820
M96821
M96830
M96831
N9961
N99820
N99821
Q282
Q283
R0989****
R203
R208
R209
R260
R261
R270
R278
R279
R295
R42
R55***
R561
R683
S090XXA
S090XXD
H34812
H349
H4921
H4943
H53123
H53413
H53452
H59111
H59211
H59311
H9521
I6002
I6031
I608
I616
I63032
I6319
I63332
I63512
I6503
I6602
I6622
I6781
I6990
I69964
I7091
I776
I9752
J9572
K91841
M303
M316
N9962
R200
R2681
R4701
S090XXS
H34813
H3582
H4922
H499
H53131
H53421
H53453
H59112
H59212
H59312
H9522
I6010
I6032
I609
I618
I6309
I6320
I63411
I63521
I651
I6603
I6623
I6782
I69920
I69965
I720
I7789
I97610
J95830
L7601
M310
M96810
N9971
R201
R2689
R471
S15001A
H34821
H4901
H4923
H52511
H53132
H53422
H53461
H59113
H59213
H59313
H9531
I6011
I604
I610
I619
I6310
I6329
I63412
I63522
I6521
I6609
I663
I67848
I69921
I69969
I728
I779
I97611
J95831
L7602
M311
M96811
N9972
R202
R269
R5084
S15001D
* Use G9389 to identify assessment of suspected brain death, ** Use I749 to report paradoXical cerebral embolism, *** Use R55 when
symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, **** Use R0989 to report carotid bruit
ICD-10 Special Bulletin, No. 8
29
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S15002A
S15002D
S15009A
S15009D
S15011A
S15021A
S15021D
S15022A
S15022D
S15091A
S15211A
S15211D
S15212A
S15212D
S15221A
S15291A
S15291D
S15292A
S15292D
S15311A
S15321A
S15321D
S15322A
S15322D
S15391A
S158XXA
S158XXD
S159XXA
S159XXD
S159XXS
S25111D
S25112A
S25112D
S25121A
S25121D
S25191D
S25192A
S25192D
T794XXA T794XXD
T80310A
T80310D
T80310S
T80311A
T80311D
T80319S
T8039XA
T8039XD
T8039XS
T8040XA
T80410D
T80410S
T80411A
T80411D
T80411S
T8049XA
T80910A
T80910D
T80910S
T80911A
T80A0XA
T80A0XD T80A0XS
T80A10A
T80A10D
T80A11S
T80A19A
T80A19D
T80A19S
T80A9XA
T8130XD
T8131XA
T8131XD
T8131XS
T8132XA
T8133XD
T8133XS
T81500A
T81500D
T81500S
T81502A
T81502D
T81502S
T81503A
T81503D
T81505D
T81505S
T81506A
T81506D
T81506S
T81508A
T81508D
T81508S
T81509A
T81510A
T81511D
T81511S
T81512A
T81512D
T81512S
T81514A
T81515A
T81515D
T81515S
T81516A
T81517D
T81517S
T81518A
T81518D
T81518S
T81520S
T81521A
T81521D
T81521S
T81522A
T81523D
T81523S
T81524A
T81525A
T81525D
T81526S
T81527A
T81527D
T81527S
T81528A
T81530A
T81530D
T81530S
T81531A
T81532A
T81536A
T81537A
T81538A
T81539A
T81590A
T81594A
T81595A
T81596A
T81597A
T81598A
T8160XS
T8161XA
T8169XA
T8169XD
T8169XS
T82390A
T82390D
T82390S
T82391A
T82391D
T82392S
T8249XA
T8249XD
T8249XS
T82590A
T82591D
T82591S
T82593A
T82593D
T82593S
T82598A
T82598D
T82598S
T888XXA
T888XXD
Z95828
Z9862
S15011D
S15091D
S15221D
S15311D
S15391D
S178XXA
S25122A
T8030XA
T80311S
T8040XD
T80419A
T80911D
T80A10S
T80A9XD
T8132XD
T81501A
T81503S
T81507A
T81510D
T81513A
T81516D
T81519A
T81522D
T81525S
T81528D
T81533A
T81591A
T81599A
T8183XA
T82391S
T82590D
T82595A
T888XXS
S15012A
S15092A
S15222A
S15312A
S15392A
S178XXD
S25122D
T8030XD
T80319A
T8040XS
T80419D
T80911S
T80A11A
T80A9XS
T8132XS
T81501D
T81504A
T81507D
T81510S
T81513D
T81516S
T81520A
T81522S
T81526A
T81528S
T81534A
T81592A
T8160XA
T8183XD
T82392A
T82590S
T82595D
Z09
S15012D
S15092D
S15222D
S15312D
S15392D
S25111A
S25191A
T8030XS
T80319D
T80410A
T80419S
T80919A
T80A11D
T8130XA
T8133XA
T81501S
T81505A
T81507S
T81511A
T81513S
T81517A
T81520D
T81523A
T81526D
T81529A
T81535A
T81593A
T8160XD
T8183XS
T82392D
T82591A
T82595S
Z95820
* Use G9389 to identify assessment of suspected brain death, ** Use I749 to report paradoXical cerebral embolism, *** Use R55 when
symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, **** Use R0989 to report carotid bruit
ICD-10 Special Bulletin, No. 8
30
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
In addition to the diagnosis codes in the above table, procedure codes 93886 and 93888 may be reimbursed when
they are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D5700
D5702
D571
D5720
D57212
D57219
D5780
D57812
D57819
Peripheral arterial Doppler procedure codes 93922, 93923, 93924, 93925, 93926, 93930, and 93931 may be
reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:
Peripheral Arterial Doppler Section 1: Eligible Diagnosis Codes for All Peripheral Arterial
Doppler Study Procedure Codes
Procedure Codes
D7801
D7802
E1059
E1151
E3612
G540
H59111
H59112
H59211
H59212
H59311
H59312
H9521
H9522
I208
I209
I214
I240
I25118
I25119
I25708
I25709
I25738
I25739
I25768
I25769
I25812
I2589
I70211
I70212
I70233
I70234
I70261
I70262
I70311
I70312
I70328
I70329
I70411
I70412
I70503
I70508
I70521
I70522
I70549
I70561
I70593
I70598
I70611
I70612
I70628
I70629
I70692
I70693
I70709
I70711
I70723
I70728
ICD-10 Special Bulletin, No. 8
D7811
E1159
G9731
H59113
H59213
H59313
H9531
I2101
I241
I252
I25710
I25750
I25790
I2602
I70213
I70238
I70263
I70313
I7035
I70413
I70509
I70523
I70562
I70599
I70613
I70639
I70698
I70712
I70729
D7812
E1351
G9732
H59119
H59219
H59319
H9532
I2102
I248
I253
I25711
I25751
I25791
I2692
I70221
I70241
I70301
I70318
I70368
I70421
I70511
I70528
I70563
I70601
I70618
I70649
I70699
I70713
I70738
D7821
E1359
G9748
H59121
H59221
H59321
H9541
I2109
I249
I2541
I25718
I25758
I25798
I700
I70222
I70242
I70302
I70319
I70369
I70422
I70512
I70529
I70568
I70602
I70619
I7065
I70701
I70718
I70739
31
D7822
E3601
G9749
H59122
H59222
H59322
H9542
I2111
I2510
I2542
I25719
I25759
I25799
I70201
I70223
I70243
I70303
I70321
I70391
I70423
I70513
I70538
I70569
I70603
I70621
I70668
I70702
I70719
I70748
E1051
E3602
G9751
H59123
H59223
H59323
I200
I2119
I25110
I25700
I25730
I25760
I25810
I70202
I70231
I70244
I70308
I70322
I70392
I70501
I70518
I70539
I70591
I70608
I70622
I70669
I70703
I70721
I70749
E1052
E3611
G9752
H59129
H59229
H59329
I201
I2129
I25111
I25701
I25731
I25761
I25811
I70203
I70232
I70248
I70309
I70323
I70393
I70502
I70519
I70548
I70592
I70609
I70623
I70691
I70708
I70722
I7075
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure Codes
I70761
I70762
I70798
I70799
I712
I713
I7300
I731
I745
I748
I772
I773
I7779
I7789
I9742
I9751
J9562
J9571
K9172
K91840
L7622
L98411
L98423
L98424
M25551
M25552
M3489
M349
M79631
M79632
M79671
M79672
N183
N184
N99820
N99821
R1905
R1906
S358X9D
S45091A
S45112D
S45191A
S45212D
S45291A
S45812D
S45891A
S55011D
S55012A
S55112D
S55191A
S65092A
S65111A
S65292A
S65311A
S65412A
S65419A
S65510A
S65511A
S65518A
S65590A
S65597A
S65598A
S75021A
S75021D
S75111A
S75111D
S75191A
S75191D
S75221A
S75221D
S85001A
S85001D
S85091A
S85091D
S85109A
S85131A
ICD-10 Special Bulletin, No. 8
I70763
I7092
I714
I7381
I749
I775
I779
I9752
J9572
K91841
L98412
L98429
M314
M79601
M79641
M96810
N185
Q279
R1907
S45091D
S45191D
S45291D
S45891D
S55012D
S55192A
S65112A
S65311D
S65491A
S65512A
S65591A
S65598D
S75022A
S75112A
S75192A
S75222A
S85002A
S85092A
S85131D
I70768
I7100
I715
I7389
I7581
I776
I798
I97610
J95830
L7601
L98413
L98491
M315
M79602
M79642
M96811
N186
R1900
R5084
S45092A
S45192A
S45292A
S45891S
S55091A
S65011A
S65191A
S65312A
S65491D
S65513A
S65592A
S65599D
S75022D
S75112D
S75192D
S75222D
S85002D
S85092D
S85132A
I70769
I7101
I716
I739
I7589
I7771
I96
I97611
J95831
L7602
L98414
L98492
M316
M79604
M79651
M96820
N9961
R1901
R561
S45092D
S45192D
S45292D
S45892A
S55092A
S65011D
S65192A
S65312D
S65492A
S65514A
S65593A
S75011A
S75091A
S75121A
S75211A
S75291A
S85011A
S85101A
S85132D
32
I70791
I7102
I718
I7401
I76
I7772
I97410
I97618
K9161
L7611
L98419
L98493
M340
M79605
M79652
M96821
N9962
R1902
S2590XA
S45111A
S45211A
S45811A
S45892D
S55111A
S65012A
S65211D
S65391A
S65492D
S65515A
S65594A
S75011D
S75091D
S75121D
S75211D
S75291D
S85011D
S85101D
S85141A
I70792
I7103
I723
I7409
I770
I7773
I97411
I9762
K9162
L7612
L98421
L98494
M341
M79621
M79661
M96830
N9971
R1903
S2590XD
S45111D
S45211D
S45811D
S45892S
S55111D
S65012D
S65212D
S65392A
S65499D
S65516A
S65595A
S75012A
S75092A
S75122A
S75212A
S75292A
S85012A
S85102A
S85141D
I70793
I711
I728
I7411
I771
I7774
I97418
J9561
K9171
L7621
L98422
L98499
M342
M79622
M79662
M96831
N9972
R1904
S358X9A
S45112A
S45212A
S45812A
S55011A
S55112A
S65091A
S65291A
S65411A
S65499S
S65517A
S65596A
S75012D
S75092D
S75122D
S75212D
S75292D
S85012D
S85102D
S85142A
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure Codes
S85142D
S85151A
S85172D
S85181A
S85391A
S85392A
S85502A
S85502D
S85592A
S85592D
S85892A
S85892D
S95192A
S95192D
T80311A
T80311D
T8039XS
T8040XA
T80411D
T80411S
T80910S
T80911A
T80A10A
T80A10D
T80A19S
T80A9XA
T8132XD
T8132XS
T8172XA
T8172XD
T82391S
T82392D
T82590S
T82591A
T82595D
T82595S
T82817A
T82817D
T82827S
T82828A
T82838D
T82838S
T82857A
T82857D
T82867S
T82868A
T82898D
T82898S
T8382XA
T8382XD
T8384XS
T8385XA
T8389XD
T8389XS
T8482XA
T8482XD
T8484XS
T8485XA
T8489XD
T8489XS
T8582XA
T8582XD
T8584XS
T8585XA
T8589XD
T8589XS
T8603
T8609
T8621
T8622
T8643
T8649
T86851
T86852
T86899
T8690
ICD-10 Special Bulletin, No. 8
S85151D
S85181D
S85411A
S85511A
S85811A
S95111A
T8030XA
T80311S
T8040XD
T80419A
T80911D
T80A10S
T80A9XD
T81718A
T8172XS
T82392S
T82591D
T82598A
T82817S
T82828D
T82847A
T82857S
T82868D
T829XXA
T8382XS
T8385XD
T839XXA
T8482XS
T8485XD
T849XXA
T8582XS
T8585XD
T859XXA
T8610
T8623
T86810
T86858
T8691
S85152A
S85182A
S85412A
S85511D
S85811D
S95111D
T8030XD
T80319A
T8040XS
T80419D
T80911S
T80A11A
T80A9XS
T81718D
T82390A
T8249XA
T82591S
T82598D
T82818A
T82828S
T82847D
T82858A
T82868S
T829XXD
T8383XA
T8385XS
T839XXD
T8483XA
T8485XS
T849XXD
T8583XA
T8585XS
T859XXD
T8611
T86290
T86811
T86859
T8692
S85152D
S85182D
S85491A
S85512A
S85812A
S95112A
T8030XS
T80319D
T80410A
T80419S
T80919A
T80A11D
T8131XA
T81718S
T82390D
T8249XD
T82593A
T82598S
T82818D
T82837A
T82847S
T82858D
T82897A
T829XXS
T8383XD
T8386XA
T839XXS
T8483XD
T8486XA
T849XXS
T8583XD
T8586XA
T859XXS
T8612
T86298
T86812
T86890
T8693
33
S85171A
S85311A
S85492A
S85512D
S85812D
S95112D
T80310A
T80319S
T80410D
T8049XA
T80A0XA
T80A11S
T8131XD
T81719A
T82390S
T8249XS
T82593D
T827XXA
T82818S
T82837D
T82848A
T82858S
T82897D
T8381XA
T8383XS
T8386XD
T8481XA
T8483XS
T8486XD
T8581XA
T8583XS
T8586XD
T8600
T8613
T8640
T86818
T86891
T8699
S85171D
S85311D
S85501A
S85591A
S85891A
S95191A
T80310D
T8039XA
T80410S
T80910A
T80A0XD
T80A19A
T8131XS
T81719D
T82391A
T82590A
T82593S
T827XXD
T82827A
T82837S
T82848D
T82867A
T82897S
T8381XD
T8384XA
T8386XS
T8481XD
T8484XA
T8486XS
T8581XD
T8584XA
T8586XS
T8601
T8619
T8641
T86819
T86892
T871X1
S85172A
S85312A
S85501D
S85591D
S85891D
S95191D
T80310S
T8039XD
T80411A
T80910D
T80A0XS
T80A19D
T8132XA
T81719S
T82391D
T82590D
T82595A
T827XXS
T82827D
T82838A
T82848S
T82867D
T82898A
T8381XS
T8384XD
T8389XA
T8481XS
T8484XD
T8489XA
T8581XS
T8584XD
T8589XA
T8602
T8620
T8642
T86850
T86898
T871X2
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure Codes
T888XXA
Z01810
Z01818
Z09
Z4803
Z955
Z95820
Z95828
Z9861
Z9862
Combination Diagnosis Codes (Must be submitted together)
E1151,
E1165
Z48812
Z86711
Z951
Procedure codes 93886 and 93888 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Section 2 includes additional diagnosis codes for upper extremity conditions.
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I742
S45311D
S45392A
S45812S
S45899D
S45991A
S55211S
S55292D
S55891A
S55911S
S55992D
S65891A
S65911S
S65992D
I75011
S45311S
S45392D
S45891A
S45899S
S45991D
S55212A
S55292S
S55891D
S55912A
S55992S
S65891D
S65912A
S65992S
I75012
S45312A
S45392S
S45891D
S45911A
S45991S
S55212D
S55811A
S55891S
S55912D
S65811A
S65891S
S65912D
T870X1
I75013
S45312D
S45811A
S45891S
S45911D
S45992A
S55212S
S55811D
S55892A
S55912S
S65811D
S65892A
S65912S
T870X2
M79A11
S45312S
S45811D
S45892A
S45911S
S45992D
S55291A
S55811S
S55892D
S55991A
S65811S
S65892D
S65991A
T870X9
M79A12
S45391A
S45811S
S45892D
S45912A
S45992S
S55291D
S55812A
S55892S
S55991D
S65812A
S65892S
S65991D
Q2731
S45391D
S45812A
S45892S
S45912D
S55211A
S55291S
S55812D
S55911A
S55991S
S65812D
S65911A
S65991S
S45311A
S45391S
S45812D
S45899A
S45912S
S55211D
S55292A
S55812S
S55911D
S55992A
S65812S
S65911D
S65992A
Procedure codes 93886 and 93888 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Section 3 includes additional diagnosis codes for lower extremity conditions.
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
L89500
L89501
L89502
L89503
L89504
L89509
L89512
L89513
L89514
L89519
L89520
L89521
L89524
L89529
L97111
L97112
L97113
L97114
L97122
L97123
L97124
L97129
L97211
L97212
L97219
L97221
L97222
L97223
L97224
L97229
L97313
L97314
L97319
L97321
L97322
L97323
L97401
L97411
L97412
L97413
L97414
L97419
L97423
L97424
L97429
L97511
L97512
L97513
L97521
L97522
L97523
L97524
L97529
L97911
L97914
L97919
L97921
L97922
L97923
L97924
M79A22
Q2732
S75811A
S75811D
S75811S
S75812A
S75819A
S75819D
S75819S
S75891A
S75891D
S75891S
ICD-10 Special Bulletin, No. 8
34
L89510
L89522
L97119
L97213
L97311
L97324
L97421
L97514
L97912
L97929
S75812D
S75892A
L89511
L89523
L97121
L97214
L97312
L97329
L97422
L97519
L97913
M79A21
S75812S
S75892D
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S75892S
S75911A
S75911D
S75911S
S75912A
S75991D
S75991S
S75992A
S75992D
S75992S
S85812A
S85812D
S85812S
S85891A
S85891D
S85892S
S85911A
S85911D
S85911S
S85912A
S85991D
S85991S
S85992A
S85992D
S85992S
S95812A
S95812D
S95812S
S95891A
S95891D
S95892S
S95911A
S95911D
S95911S
S95912A
S95991D
S95991S
S95992A
S95992D
S95992S
S75912D
S85811A
S85891S
S85912D
S95811A
S95891S
S95912D
S75912S
S85811D
S85892A
S85912S
S95811D
S95892A
S95912S
S75991A
S85811S
S85892D
S85991A
S95811S
S95892D
S95991A
Peripheral venous Doppler procedure codes 93965, 93970, and 93971 may be reimbursed when they are submitted
with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D7811
D7812
E3611
E3612
G9748
H59213
H59219
H59221
H59222
H59223
I2602
I2690
I2692
I2699
I2782
I8001
I8002
I8003
I8011
I8012
I80221
I80222
I80223
I80231
I80213
I80292
I80293
I803
I808
I809
I82291
I82401
I82402
I82403
I82411
I82422
I82423
I82431
I82432
I82433
I824Z1
I824Z2
I824Z3
I82501
I82502
I82513
I82521
I82522
I82523
I82531
I82542
I82543
I825Y1
I825Y2
I825Y3
I82601
I82602
I82603
I82611
I82612
I82623
I82701
I82702
I82703
I82711
I82722
I82723
I82811
I82812
I82813
I82A12
I82A13
I82A21
I82A22
I82A23
I82B21
I82B22
I82B23
I82C11
I82C12
I82C23
I83011
I83012
I83013
I83014
I83021
I83022
I83023
I83024
I83025
I8312
I83204
I83211
I83212
I83213
I83219
I83221
I83222
I83223
I83224
I83811
I83812
I83813
I83891
I83892
I87002
I87003
I87011
I87012
I87013
I87031
I87032
I87033
I87091
I87092
I87302
I87303
I87311
I87312
I87313
I87331
I87332
I87333
I87391
I87392
J9571
J9572
K9171
K9172
L7611
L89502
L89503
L89504
L89509
L89510
L89514
L89519
L89520
L89521
L89522
ICD-10 Special Bulletin, No. 8
35
G9749
H59229
I7401
I8013
I80232
I82220
I82412
I824Y1
I82503
I82532
I825Z1
I82613
I82712
I82890
I82B11
I82C13
I83015
I83028
I83214
I83225
I83893
I87021
I87093
I87321
I87393
L7612
L89511
L89523
H59211
H9531
I7409
I80211
I80233
I82221
I82413
I824Y2
I82511
I82533
I825Z2
I82621
I82713
I82891
I82B12
I82C21
I83018
I83029
I83215
I83228
I8390
I87022
I871
I87322
I9751
L89500
L89512
L89524
H59212
H9532
I749
I80212
I80291
I82290
I82421
I824Y3
I82512
I82541
I825Z3
I82622
I82721
I82A11
I82B13
I82C22
I83019
I8311
I83218
I83229
I87001
I87023
I87301
I87323
I9752
L89501
L89513
L89529
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
L97111
L97112
L97113
L97114
L97119
L97124
L97129
L97211
L97212
L97213
L97222
L97223
L97224
L97229
L97311
L97319
L97321
L97322
L97323
L97324
L97412
L97413
L97414
L97419
L97421
L97429
L97511
L97512
L97513
L97514
L97523
L97524
L97529
L97911
L97912
L97921
L97922
L97923
L97924
L97929
M79602
M79604
M79605
M79621
M79622
M79642
M79651
M79652
M79661
M79662
M79A12
M79A21
M79A22
M96820
M96821
O2221
O2222
O2223
O2230
O2231
O2291
O2292
O2293
O870
O871
O88213
O88219
O8822
O8823
Q2731
R220
R221
R222
R2231
R2232
R2243
R5084
R561
R600
R601
S358X9A
S358X9D
S45091A
S45091D
S45092A
S45112A
S45112D
S45191A
S45191D
S45192A
S45212A
S45212D
S45291A
S45291D
S45292A
S45391A
S45392A
S45811A
S45811D
S45812A
S45891S
S45892A
S45892D
S45892S
S45899A
S45992A
S55011A
S55011D
S55012A
S55012D
S55111D
S55112A
S55112D
S55191A
S55192A
S55292A
S55811A
S55812A
S55891A
S55892A
S55992A
S65011A
S65011D
S65012A
S65012D
S65112A
S65191A
S65192A
S65211D
S65212D
S65311D
S65312A
S65312D
S65391A
S65392A
S65491A
S65491D
S65492A
S65492D
S65499D
S65512A
S65513A
S65514A
S65515A
S65516A
S65591A
S65592A
S65593A
S65594A
S65595A
S65598D
S65599D
S65811A
S65811D
S65812A
S65911A
S65911D
S65912A
S65991A
S65992A
S75012D
S75021A
S75021D
S75022A
S75022D
S75092D
S75111A
S75111D
S75112A
S75112D
S75122D
S75191A
S75191D
S75192A
S75192D
S75212D
S75221A
S75221D
S75222A
S75222D
S75292D
S75811A
S75812A
S75819A
S75891A
S75991A
S75992A
S85001A
S85001D
S85002A
S85012A
S85012D
S85091A
S85091D
S85092A
ICD-10 Special Bulletin, No. 8
36
L97121
L97214
L97312
L97329
L97422
L97519
L97913
M7121
M79631
M79671
N9971
O2232
O879
Q2732
R2233
R609
S45092D
S45192D
S45292D
S45812D
S45911A
S55091A
S55211A
S55911A
S65091A
S65291A
S65411A
S65499S
S65517A
S65596A
S65812D
S75011A
S75091A
S75121A
S75211A
S75291A
S75892A
S85002D
S85092D
L97122
L97219
L97313
L97401
L97423
L97521
L97914
M7122
M79632
M79672
N9972
O2233
O88211
Q278
R2241
S2590XA
S45111A
S45211A
S45311A
S45891A
S45912A
S55092A
S55212A
S55912A
S65092A
S65292A
S65412A
S65510A
S65518A
S65597A
S65891A
S75011D
S75091D
S75121D
S75211D
S75291D
S75911A
S85011A
S85101A
L97123
L97221
L97314
L97411
L97424
L97522
L97919
M79601
M79641
M79A11
O2220
O2290
O88212
Q279
R2242
S2590XD
S45111D
S45211D
S45312A
S45891D
S45991A
S55111A
S55291A
S55991A
S65111A
S65311A
S65419A
S65511A
S65590A
S65598A
S65892A
S75012A
S75092A
S75122A
S75212A
S75292A
S75912A
S85011D
S85101D
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S85102A
S85102D
S85109A
S85131A
S85131D
S85141D
S85142A
S85142D
S85151A
S85151D
S85171D
S85172A
S85172D
S85181A
S85181D
S85311D
S85312A
S85391A
S85392A
S85411A
S85501A
S85501D
S85502A
S85502D
S85511A
S85591A
S85591D
S85592A
S85592D
S85811A
S85891A
S85891D
S85892A
S85892D
S85911A
S95111A
S95111D
S95112A
S95112D
S95191A
S95811A
S95811D
S95812A
S95812D
S95891A
S95911A
S95912A
S95991A
S95992A
T801XXA
T8030XD
T8030XS
T80310A
T80310D
T80310S
T80319A
T80319D
T80319S
T8039XA
T8039XD
T8040XS
T80410A
T80410D
T80410S
T80411A
T80419D
T80419S
T8049XA
T80910A
T80910D
T80911S
T80919A
T80A0XA
T80A0XD T80A0XS
T80A11A
T80A11D
T80A11S
T80A19A
T80A19D
T80A9XS
T81718A
T81718D
T81718S
T81719A
T8172XD
T8172XS
T82390A
T82391A
T82392A
T82593A
T82595A
T82598A
T82818A
T82818D
T82838D
T82848A
T82848D
T82858A
T82858D
T888XXA
Z01818
Z86711
Z940
Z951
Combination Diagnosis Codes (Must be submitted in pairs)
T8172XA
T800XXA T81718A
T82817A
T82818A
I2690
I2690
I2690
I2690
I2690
S85132A
S85152A
S85182A
S85412A
S85511D
S85811D
S85912A
S95191D
S95891D
T801XXD
T80311A
T8039XS
T80411D
T80910S
T80A10A
T80A19S
T81719D
T8249XA
T82828A
T82868A
S85132D
S85152D
S85182D
S85491A
S85512A
S85812A
S85991A
S95192A
S95892A
T801XXS
T80311D
T8040XA
T80411S
T80911A
T80A10D
T80A9XA
T81719S
T82590A
T82828D
T82868D
S85141A
S85171A
S85311A
S85492A
S85512D
S85812D
S85992A
S95192D
S95892D
T8030XA
T80311S
T8040XD
T80419A
T80911D
T80A10S
T80A9XD
T8172XA
T82591A
T82838A
T82898A
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled Combination Diagnosis Codes on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, subsection
3.2.7.3 “Diagnostic Doppler Sonography” for additional information.
Dimethyl Sulfoxide (DMSO)
Procedure code J1212 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
N3010
N3011
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39, “Medications - Injectable,” for additional information.
ICD-10 Special Bulletin, No. 8
37
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Doctor of Dentistry Services as a Limited Physician
Immune globulin injection procedure code J1571 may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D611
D612
D613
D619
D804
D805
D838
D8982
D8989
G7000
N19
Z205
Z206
Z20828
Patient evaluation and management services and consultation procedure codes may be reimbursed when they are
submitted with the most appropriate ICD-10-CM diagnosis codes.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.3.2.2, “Evaluation and Management Procedure Codes;” and subsection
9.3.2.4, “Immune Globulin by a Doctor of Dentistry as a Limited Physician,” for additional information.
Evoked Response Tests
Electromyography (EMG) and nerve conduction studies (NCS) procedure codes may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C701
C720
C721
E0842
E0942
E1041
E1042
E10610
E1141
E1142
E1144
E11610
E1342
E5111
E5112
E512
E518
E519
E560
E568
E786
E851
E852
E853
E858
E859
G120
G121
G1221
G1222
G1229
G128
G129
G130
G243
G2589
G26
G320
G360
G370
G375
G501
G510
G511
G512
G513
G514
G518
G519
G522
G523
G527
G528
G540
G541
G542
G543
G544
G545
G548
G549
G5601
G5602
G5611
G5612
G5621
G5622
G5631
G5632
G5641
G5642
G5681
G5682
G5691
G5692
G5701
G5702
G5711
G5712
G5721
G5722
G5731
G5732
G5741
G5742
G5751
G5752
G5761
G5762
G5771
G5772
G5781
G5782
G5791
G5792
G587
G588
G589
G59
G600
G601
G602
G603
G608
G609
G610
G6181
G6189
G619
G620
G621
G622
G6281
G6282
G629
G63
G650
G651
G652
G7000
G7001
G701
G702
G7081
G7089
G709
G710
G7111
G7112
G7113
G7114
G7119
G712
G713
G718
G719
G721
G722
G723
G7241
G7249
G7281
G7289
G729
G731
G733
G737
G800
G801
G802
G803
G804
G808
G809
G8311
G8312
G8313
G8314
G8321
G8322
G8323
G8324
G834
G8381
G8382
G8383
G8384
G8389
G839
G9009
G902
G904
G9050
G90511
G90512
G90513
G90519
G90521
G90522
G90523
G90529
G9059
G909
G950
G9511
G9519
G9520
G9529
G9581
G9589
G959
G990
G992
I776
I951
J3800
J3801
J3802
K5902
K5909
K592
K594
K624
K6289
M05411
M05412
M05421
M05422
M05431
M05432
M05441
M05442
M05451
M05452
M05461
M05462
ICD-10 Special Bulletin, No. 8
38
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M05471
M05472
M0549
M05511
M05512
M05532
M05541
M05542
M05551
M05552
M05572
M0559
M05711
M05712
M05721
M05741
M05742
M05751
M05752
M05761
M05772
M05779
M0579
M05811
M05812
M05832
M05841
M05842
M05851
M05852
M05872
M0589
M06011
M06012
M06021
M06041
M06042
M06051
M06052
M06061
M0608
M0609
M06811
M06812
M06821
M06841
M06842
M06852
M06861
M06862
M0689
M069
M21271
M21272
M21331
M216X1
M216X2
M21831
M21832
M21931
M3211
M3212
M3213
M3214
M3215
M3300
M3301
M3302
M3309
M3310
M3320
M3321
M3322
M3329
M3390
M340
M341
M342
M3481
M3482
M360
M4321
M4322
M4323
M4324
M4328
M436
M438X9
M4644
M4645
M4712
M4713
M4714
M4715
M4716
M4722
M4723
M4724
M4725
M4726
M47812
M47813
M47814
M47815
M47816
M47892
M47893
M47894
M47895
M47896
M4802
M4803
M4804
M4805
M4806
M5001
M5002
M5003
M5011
M5012
M5022
M5023
M5030
M5031
M5032
M5082
M5083
M5091
M5092
M5093
M5107
M5124
M5125
M5126
M5127
M5137
M5184
M5185
M5186
M5187
M5413
M5414
M5415
M5416
M5417
M546
M5489
M60011
M60012
M60021
M60041
M60042
M60044
M60045
M60046
M60062
M60070
M60071
M60073
M60074
M6009
M60111
M60112
M60121
M60122
M60142
M60151
M60152
M60161
M60162
M6019
M609
M6250
M62511
M62512
M62529
M62531
M62532
M62539
M62541
M62552
M62559
M62561
M62562
M62569
M6258
M6259
M6281
M629
M791
M79604
M79605
M79621
M79622
M79631
M79651
M79652
M79661
M79662
M79671
N393
N3941
N3942
N3943
N3944
N39498
N94819
R150
R151
R152
R202
R203
R208
R209
R260
R269
R290
R295
R32
R3914
ICD-10 Special Bulletin, No. 8
39
M05521
M05561
M05722
M05762
M05821
M05861
M06022
M06062
M06822
M06871
M21332
M21932
M3219
M3311
M3391
M3483
M4325
M4646
M4717
M4727
M47817
M47897
M4807
M5013
M5033
M5104
M5134
M5410
M5431
M60022
M60051
M60076
M60131
M60171
M62519
M62542
M62571
M792
M79632
M79672
N3945
R159
R261
R4702
M05522
M05562
M05731
M05769
M05822
M05862
M06031
M06071
M06831
M06872
M21511
M320
M328
M3312
M3392
M3489
M4326
M4647
M4718
M4728
M47818
M47898
M4808
M5020
M5080
M5105
M5135
M5411
M5432
M60031
M60052
M60077
M60132
M60172
M62521
M62549
M62572
M79601
M79641
M797
N3946
R200
R2681
R471
M05531
M05571
M05732
M05771
M05831
M05871
M06032
M06072
M06832
M0688
M21512
M3210
M329
M3319
M3399
M358
M4327
M4711
M4721
M47811
M47891
M4801
M5000
M5021
M5081
M5106
M5136
M5412
M545
M60032
M60061
M6008
M60141
M6018
M62522
M62551
M62579
M79602
M79642
M961
N39490
R201
R2689
R4781
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R4789
R498
R6884
S14101A
S14101D
S14102S
S14103A
S14103D
S14103S
S14104A
S14105D
S14105S
S14106A
S14106D
S14106S
S14108A
S14108D
S14108S
S14109A
S14109D
S14111S
S14112A
S14112D
S14112S
S14113A
S14114D
S14114S
S14115A
S14115D
S14115S
S14117A
S14117D
S14117S
S14118A
S14118D
S14121S
S14122A
S14122D
S14122S
S14123A
S14124D
S14124S
S14125A
S14125D
S14125S
S14127A
S14127D
S14127S
S14128A
S14128D
S14131S
S14132A
S14132D
S14132S
S14133A
S14134D
S14134S
S14135A
S14135D
S14135S
S14137A
S14137D
S14137S
S14138A
S14138D
S14141S
S14142A
S14142D
S14142S
S14143A
S14144D
S14144S
S14145A
S14145D
S14145S
S14147A
S14147D
S14147S
S14148A
S14148D
S14151S
S14152A
S14152D
S14152S
S14153A
S14154D
S14154S
S14155A
S14155D
S14155S
S14157A
S14157D
S14157S
S14158A
S14158D
S142XXS
S143XXA
S143XXD
S143XXS
S144XXA
S145XXD
S145XXS
S148XXA
S148XXD
S148XXS
S24101A
S24101D
S24101S
S24102A
S24102D
S24103S
S24104A
S24104D
S24104S
S24109A
S24111D
S24111S
S24112A
S24112D
S24112S
S24114A
S24114D
S24114S
S24131A
S24131D
S24132S
S24133A
S24133D
S24133S
S24134A
S24141D
S24141S
S24142A
S24142D
S24142S
S24144A
S24144D
S24144S
S24151A
S24151D
S24152S
S24153A
S24153D
S24153S
S24154A
S242XXD
S242XXS
S243XXA
S243XXD
S243XXS
S248XXA
S248XXD
S248XXS
S249XXA
S34109A
S34111S
S34112A
S34112D
S34112S
S34113A
S34114D
S34114S
S34115A
S34115D
S34115S
S34122A
S34122D
S34122S
S34123A
S34123D
S34124S
S34125A
S34125D
S34125S
S34131A
S34132D
S34132S
S34139A
S34139D
S34139S
S3422XA
S3422XD
S3422XS
S343XXA
S343XXD
S344XXS
S345XXA
S345XXD
S345XXS
S4400XA
S4401XD
S4401XS
S4402XA
S4402XD
S4402XS
S4411XA
S4411XD
S4411XS
S4412XA
S4412XD
S4420XS
S4421XA
S4421XD
S4421XS
S4422XA
S4430XD
S4430XS
S4431XA
S4431XD
S4431XS
S4440XA
S4440XD
S4440XS
S4441XA
S4441XD
S4442XS
S4450XA
S4450XD
S4450XS
S4451XA
ICD-10 Special Bulletin, No. 8
40
S14101S
S14104D
S14107A
S14109S
S14113D
S14116A
S14118S
S14123D
S14126A
S14128S
S14133D
S14136A
S14138S
S14143D
S14146A
S14148S
S14153D
S14156A
S14158S
S144XXD
S149XXA
S24102S
S24109D
S24113A
S24131S
S24134D
S24143A
S24151S
S24154D
S244XXA
S34109D
S34113D
S34121A
S34123S
S34131D
S3421XA
S343XXS
S4400XD
S4410XA
S4412XS
S4422XD
S4432XA
S4441XS
S4451XD
S14102A
S14104S
S14107D
S14111A
S14113S
S14116D
S14121A
S14123S
S14126D
S14131A
S14133S
S14136D
S14141A
S14143S
S14146D
S14151A
S14153S
S14156D
S142XXA
S144XXS
S149XXD
S24103A
S24109S
S24113D
S24132A
S24134S
S24143D
S24152A
S24154S
S244XXD
S34111A
S34113S
S34121D
S34124A
S34131S
S3421XD
S344XXA
S4400XS
S4410XD
S4420XA
S4422XS
S4432XD
S4442XA
S4451XS
S14102D
S14105A
S14107S
S14111D
S14114A
S14116S
S14121D
S14124A
S14126S
S14131D
S14134A
S14136S
S14141D
S14144A
S14146S
S14151D
S14154A
S14156S
S142XXD
S145XXA
S149XXS
S24103D
S24111A
S24113S
S24132D
S24141A
S24143S
S24152D
S242XXA
S244XXS
S34111D
S34114A
S34121S
S34124D
S34132A
S3421XS
S344XXD
S4401XA
S4410XS
S4420XD
S4430XA
S4432XS
S4442XD
S4452XA
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S4452XD
S4452XS
S448X1A
S448X1D
S448X1S
S448X9A
S448X9D
S448X9S
S4491XA
S4491XD
S4492XS
S5400XA
S5400XD
S5400XS
S5401XA
S5402XD
S5402XS
S5410XA
S5410XD
S5410XS
S5412XA
S5412XD
S5412XS
S5420XA
S5420XD
S5421XS
S5422XA
S5422XD
S5422XS
S5430XA
S5431XD
S5431XS
S5432XA
S5432XD
S5432XS
S5491XA
S5491XD
S5491XS
S5492XA
S5492XD
S6400XS
S6401XA
S6401XD
S6401XS
S6402XA
S6410XD
S6410XS
S6411XA
S6411XD
S6411XS
S6420XA
S6420XD
S6420XS
S6421XA
S6421XD
S6422XS
S6430XA
S6430XD
S6430XS
S6431XA
S6432XD
S6432XS
S64490A
S64490D
S64490S
S64492A
S64492D
S64492S
S64493A
S64493D
S64494S
S64495A
S64495D
S64495S
S64496A
S64497D
S64497S
S64498A
S64498D
S64498S
S648X2A
S648X2D
S648X2S
S648X9A
S648X9D
S6490XS
S6491XA
S6491XD
S6491XS
S6492XA
S7402XA
S7402XD
S7402XS
S7411XA
S7411XD
S7412XS
S7421XA
S7421XD
S7421XS
S7422XA
S748X1D
S748X1S
S748X2A
S748X2D
S748X2S
S7492XA
S7492XD
S7492XS
S8401XA
S8401XD
S8402XS
S8411XA
S8411XD
S8411XS
S8412XA
S8421XD
S8421XS
S8422XA
S8422XD
S8422XS
S84802A
S84802D
S84802S
S8491XA
S8491XD
S8492XS
S9421XA
S9421XD
S9421XS
S9422XA
S9431XD
S9431XS
S9432XA
S9432XD
S9432XS
S948X2A
S948X2D
S948X2S
S948X9D
S948X9S
S9492XA
S9492XD
S9492XS
S448X2A
S4491XS
S5401XD
S5411XA
S5420XS
S5430XD
S5490XA
S5492XS
S6402XD
S6412XA
S6421XS
S6431XD
S64491A
S64493S
S64496D
S648X1A
S648X9S
S7401XA
S7411XS
S7422XD
S7491XA
S8401XS
S8412XD
S84801A
S8491XS
S9422XD
S948X1A
S9490XD
S448X2D
S4492XA
S5401XS
S5411XD
S5421XA
S5430XS
S5490XD
S6400XA
S6402XS
S6412XD
S6422XA
S6431XS
S64491D
S64494A
S64496S
S648X1D
S6490XA
S7401XD
S7412XA
S7422XS
S7491XD
S8402XA
S8412XS
S84801D
S8492XA
S9422XS
S948X1D
S9491XA
S448X2S
S4492XD
S5402XA
S5411XS
S5421XD
S5431XA
S5490XS
S6400XD
S6410XA
S6412XS
S6422XD
S6432XA
S64491S
S64494D
S64497A
S648X1S
S6490XD
S7401XS
S7412XD
S748X1A
S7491XS
S8402XD
S8421XA
S84801S
S8492XD
S9431XA
S948X1S
S9491XS
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.28.2, “Electromyography and Nerve Conduction Studies,” for
additional information.
Genetic Testing for Colorectal Cancer
ICD-10-CM diagnosis code Z800 will only be allowed on the claim when it is submitted with the following
procedure codes:
Procedure Codes
81201
81202
81297
81298
81203
81299
81210
81300
81275
81301
81292
81317
81293
81318
81294
81319
81295
81296
Refer to: The Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physicians
Assistants Handbook, subsection 9.2.15.3, “Genetic Testing for Colorectal Cancer,” for more information.
ICD-10 Special Bulletin, No. 8
41
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Family Planning Diagnosis Codes
Family planning annual examinations may be reimbursed when the applicable evaluation and management (E/M)
procedure code is submitted with one of the following family planning ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z30011
Z30013 Z30014
Z30018
Z3002
Z3009
Z302
Z3040
Z3041
Z3042
Z30430 Z30431 Z30432 Z30433 Z3049
Z308
Z309
Z9851
Z9852
Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health and Family
Planning Services Handbook, subsection 5.6, “Diagnostic Hysteroscopy;” subsection 3.3.8.6, “TWHP
Services After Sterilization;” subsection 5.12, “Surgery for Masculinized Females;” and subsection 2.2,
“Services, Benefits, Limitations, and Prior Authorization,” for additional information.
Gynecological and Reproductive Health Services
Effective for dates of service on or after October 1, 2015, diagnostic hysteroscopy procedure code 58555 is restricted
to the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D250
N840
N8500
N856
N897
N920
N921
N923
N924
N925
N930
N938
N950
Q5110
Q5111
Q512
Q51818
Hysterosalpingography procedure code 74740 may be reimbursed when billed with diagnosis code Z302.
Surgical correction of abnormalities of the external genitalia for masculinized females (procedure codes 56805 and
57335) may be reimbursed for clients who are 20 years of age and younger when one of the following ICD-10-CM
diagnosis codes is submitted on the claim:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E250
E258
E259
E271
E272
E2740
E2749
Q561
Q562
Q563
Q564
E3450
E3451
E3452
Q560
Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health Services Handbook,
subsection 3.3, “Services, Benefits, Limitations, and Prior Authorization,” for additional information.
Hearing Devices
Prior authorization for a unilateral or bilateral cochlear implant may be granted for clients who are 12 months
of age and older with appropriate documentation of the required criteria and the most appropriate ICD-10-CM
diagnosis code.
Prior authorization for the auditory brainstem implant (ABI) may be granted for clients who are 12 years of age or
older and is limited to a condition of neurofibromatosis, type II or schwannomatosis.
Prior authorization for the bone anchored hearing aid (BAHA) device may be granted for clients who are five
years of age or older with documentation of an appropriate ICD-10-CM diagnosis code that indicates a condition
including, but not limited to, one of the following:
• Conductive hearing loss
• Sensorineural hearing loss
• Other anomalies of external ear with impairment of hearing
• Anomalies of skull and face bones
ICD-10 Special Bulletin, No. 8
42
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Refer to: The Texas Medicaid Provider Procedures Manual Vision and Hearing Services Handbook, subsection 3.2.1.1,
“Prior Authorization;” subsection 3.2.2.1, “Prior Authorization;” and subsection 3.2.3.1, “Prior Authorization,” for information about the required criteria documentation that must be submitted with prior
authorization requests.
Helicobactor Pylori
Serology testing (procedure codes 83009 and 86677), breath testing (procedure codes 78267, 78268, 83013 and
83014), and stool testing (procedure code 87338) may be reimbursed when they are submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C160
C161
C162
C163
C164
C165
C166
C168
K250
K251
K252
K253
K254
K255
K256
K257
K260
K261
K262
K263
K264
K265
K266
K267
K270
K271
K272
K273
K274
K275
K276
K277
K280
K281
K282
K283
K284
K285
K286
K287
K2900
K2901
K2920
K2921
K2931
K2940
K2941
K2960
K2961
K2980
K2981
K2990
K2991
Additionally, H. Pylori breath and stool testing procedure codes 78267, 78268, 83013, and 83014 may be
reimbursed when submitted with ICD-10-CM diagnosis code B9681.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.26.8, “Helicobacter Pylori (H. pylori),” for additional information.
Hematopoietic Injections
Procedure code J0881 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C9000
C9001
C9002
D460
D461
D4621
D46A
D46B
D611
D612
D613
D6189
D619
D630
D631
D644
D6481
D6489
D649
N181
N182
N183
N184
N185
N186
N189
N19
Z5111
Z5112
Procedure code J0882 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D631
N181
N182
N183
N184
N185
N186
N189
N19
Procedure code J0885 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B20
C9000
C9001
C9002
D460
D461
D4621
D4622
D464
D469
D46A
D46B
D46C
D46Z
D471
D479
D47Z9
D611
D612
D613
D6189
D619
D630
D631
D644
D6481
D6489
D649
N181
N182
N183
N184
N185
N186
N189
N19
P612
ICD-10 Special Bulletin, No. 8
43
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure code J0886 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D631
N181
N182
N183
N184
N185
N186
N189
N19
Refer to: The Texas Medicaid Provider Procedures Manual Clinics and Other Outpatient Facility Services Handbook,
subsection 6.2.9.4, “Hematopoietic Injections;” and the Medical and Nursing Specialists, Physicians, and
Physician Assistants Handbook, subsection 9.2.39.13, “Hematopoietic Injections,” for additional information.
Hepatitis Prophylaxis (Hepatitis B Immune Globulin and Hepatitis B Vaccine, Dialysis)
Hepatitis immune globulin (HBIg) procedure codes 90371, J1571, and J1573 may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z205
Z206
Z20828
HBIg procedure codes 90740 and 90747 for dialysis use are not restricted to specific diagnosis codes. The most
appropriate ICD-10-CM diagnosis code or code combination must be submitted with the claim.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.37, “Immunizations for Clients Who Are 21 Years of Age or Older,”
for additional information.
Injections – Chelating Agents
Procedure code J3520 may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E8352
T460X1A
T460X1D
T460X1S
T460X2A
T460X2D
T460X2S
T460X3A
T460X3D
T460X3S
T460X4A
T460X4D
T460X4S
Procedure code J0470 may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T560X1A
T560X1D
T560X1S
T560X2A
T560X2D
T560X2S
T560X3A
T560X3D
T560X3S
T560X4A
T560X4D
T560X4S
T561X1A
T561X1D
T561X1S
T561X2A
T561X2D
T561X2S
T561X3A
T561X3D
T561X3S
T561X4A
T561X4D
T561X4S
T564X1A
T564X1D
T564X1S
T564X2A
T564X2D
T564X2S
T564X3A
T564X3D
T564X3S
T564X4A
T564X4D
T564X4S
T565X1A
T565X1D
T565X1S
T565X2A
T565X2D
T565X2S
T565X3A
T565X3D
T565X3S
T565X4A
T565X4D
T565X4S
T566X1A
T566X1D
T566X1S
T566X2A
T566X2D
T566X2S
T566X3A
T566X3D
T566X3S
T566X4A
T566X4D
T566X4S
T56811A
T56811D
T56811S
T56812A
T56812D
T56812S
T56813A
T56813D
T56813S
T56814A
T56814D
T56814S
T56891A
T56891D
T56891S
T56892A
T56892D
T56892S
T56893A
T56893D
T56893S
T56894A
T56894D
T56894S
T5691XA
T5691XD
T5691XS
T5692XA
T5692XD
T5692XS
T5693XA
T5693XD
T5693XS
T5694XA
T5694XD
T5694XS
T570X1A
T570X1D
T570X1S
T570X2A
T570X2D
T570X2S
T570X3A
T570X3D
T570X3S
T570X4A
T570X4D
T570X4S
ICD-10 Special Bulletin, No. 8
44
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Procedure code J0600 may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T560X1A
T560X1D
T560X1S
T560X2A
T560X2D
T560X2S
T560X3A
T560X3D
T560X3S
T560X4A
T560X4D
T560X4S
T564X1A
T564X1D
T564X1S
T564X2A
T564X2D
T564X2S
T564X3A
T564X3D
T564X3S
T564X4A
T564X4D
T564X4S
T565X1A
T565X1D
T565X1S
T565X2A
T565X2D
T565X2S
T565X3A
T565X3D
T565X3S
T565X4A
T565X4D
T565X4S
T566X1A
T566X1D
T566X1S
T566X2A
T566X2D
T566X2S
T566X3A
T566X3D
T566X3S
T566X4A
T566X4D
T566X4S
T56811A
T56811D
T56811S
T56812A
T56812D
T56812S
T56813A
T56813D
T56813S
T56814A
T56814D
T56814S
T56891A
T56891D
T56891S
T56892A
T56892D
T56892S
T56893A
T56893D
T56893S
T56894A
T56894D
T56894S
T5691XA
T5691XD
T5691XS
T5692XA
T5692XD
T5692XS
T5693XA
T5693XD
T5693XS
T5694XA
T5694XD
T5694XS
Procedure code J0895 may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D560
D561
D562
D563
D568
D569
D5700
D5701
D5702
D571
D5720
D57211
D57212
D57219
D5740
D57411
D57412
D57419
D5780
D57811
D57812
D57819
E83111
E83118
N181
N182
N183
N184
N185
N186
N189
N19
T454X1A
T454X1D
T454X1S
T454X2A
T454X2D
T454X2S
T454X3A
T454X3D
T454X3S
T454X4A
T454X4D
T454X4S
T470X1A
T470X1D
T470X1S
T470X2A
T470X2D
T470X2S
T470X3A
T470X3D
T470X3S
T470X4A
T470X4D
T470X4S
T471X1A
T471X1D
T471X1S
T471X2A
T471X2D
T471X2S
T471X3A
T471X3D
T471X3S
T471X4A
T471X4D
T471X4S
T564X1A
T564X1D
T564X1S
T564X2A
T564X2D
T564X2S
T564X3A
T564X3D
T564X3S
T564X4A
T564X4D
T564X4S
T565X1A
T565X1D
T565X1S
T565X2A
T565X2D
T565X2S
T565X3A
T565X3D
T565X3S
T565X4A
T565X4D
T565X4S
T566X1A
T566X1D
T566X1S
T566X2A
T566X2D
T566X2S
T566X3A
T566X3D
T566X3S
T566X4A
T566X4D
T566X4S
T56811A
T56811D
T56811S
T56812A
T56812D
T56812S
T56813A
T56813D
T56813S
T56814A
T56814D
T56814S
T56891A
T56891D
T56891S
T56892A
T56892D
T56892S
T56893A
T56893D
T56893S
T56894A
T56894D
T56894S
T5691XA
T5691XD
T5691XS
T5692XA
T5692XD
T5692XS
T5693XA
T5693XD
T5693XS
T5694XA
T5694XD
T5694XS
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39.10, “Chelating Agents,” for additional information.
ICD-10 Special Bulletin, No. 8
45
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Injections – Immune Globulins
Procedure codes 90291 and J0850 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z940
Z941
Z942
Z943
Z944
Z9483
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39.15, “Immune Globulin,” for additional information.
Iron Studies
Ferritin, iron, iron binding capacity, transferrin, iron stain, and peripheral blood lab tests (procedure codes
82728, 83540, 83550, 84466, and 85536) may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D460
D461
D4620
D4621
D4622
D464
D469
D46A
D46B
D46C
D46Z
D471
D473
D479
D47Z1
D47Z9
D500
D501
D508
D509
D511
D512
D513
D518
D519
D520
D521
D528
D529
D510
D564
D562
D563
D560
D561
D539
D532
D538
D530
D531
D568
D569
D5700
D5701
D5702
D571
D5720
D57211 D57212 D57219
D5740
D57411
D57412 D57419
D5780
D57811 D57812 D57819 D582
D588
D589
D598
D599
D630
D631
D638
D640
D641
D642
D643
D649
D732
D7381
E0801
E0810
E0811
E0821
E0822
E0829
E08311
E08319
E08321
E08329
E08331
E08339
E08341
E08349
E08351
E08359
E0836
E0839
E0840
E0841
E0842
E0843
E0844
E0849
E0851
E0859
E08610
E08618
E08620 E08621
E08622 E08628 E08630 E08638 E08641 E08649 E0865
E0869
E088
E089
E0901
E0910
E0911
E0940
E0941
E0942
E0943
E0944
E0949
E0951
E0959
E09610
E09618
E09620 E09621
E09622 E09628
E09630 E09638
E09641 E09649 E0965
E0969
E098
E099
E1010
E1011
E1021
E1022
E1029
E10311
E10319
E10321
E10329
E10331
E10339
E10341
E10349
E10351
E10359
E1036
E1039
E1040
E1041
E1042
E1043
E1044
E1049
E1051
E1052
E1059
E10610
E10618
E10620
E10621
E10622
E10628
E10630
E10638
E10641
E10649
E1065
E1069
E108
E109
E1101
E1121
E1122
E1129
E11311
E11319
E11321
E11329
E11331
E11339
E11341
E11349
E11351
E11359
E1136
E1139
E1140
E1141
E1142
E1143
E1144
E1149
E1151
E1152
E1159
E11610
E11618
E11620
E11621
E11622
E11628
E11630
E11638
E11641
E11649
E1165
E1169
E118
E119
E1301
E1310
E1311
E1321
E1322
E1329
E13311
E13319
E13321
E13329
E13331
E13339
E13341
E13349
E13351
E13359
E1336
E1339
E1340
E1341
E1342
E1343
E1344
E1349
E1351
E1352
E1359
E13610
E13620
E13621
E13622
E13628
E13630
E13638
E13641
E13649
E1365
E1369
E138
E139
E8310
E83110
E83111
E83118
E8319
G2589
G259
G26
I420
I425
I428
I43
I440
I441
I442
I4430
I4439
I444
I445
I4460
I4469
I447
I450
I4510
I4519
I452
I453
I454
I455
I456
I4581
I4589
I459
I470
I471
I472
I479
I480
I481
I482
I483
I484
I4891
I4892
I4901
I4902
I491
I493
I4940
I4949
I495
I498
I499
I501
I5020
I5021
I5022
I5023
I5030
I5031
I5032
I5033
I5040
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I5041
I5042
I5043
I509
I781
K7011
K739
K740
K741
K7460
K7469
K754
L649
L659
L818
L819
L989
M1310
M13131 M13132 M13141 M13142 M13151 M13152
M13811 M13812 M13821 M13822 M13831 M13832
M13861 M13862 M13871 M13872 M1388
M1389
M154
M158
M160
M1611
M1612
M162
M1652
M166
M167
M170
M1711
M1712
M175
M1811
M1812
M182
M19011 M19012
M19041 M19042 M19071 M19072 M19111 M19112
M19141 M19142 M19171 M19172 M19211 M19212
M19241 M19242 M19271 M19272 M1990
M1991
N5202
N5203
N521
N5231
N5232
N5233
N911
N912
N913
N914
N915
R001
R188
R740
R7871
R7879
R7889
R790
K7031
K7581
M13111
M13161
M13841
M150
M1631
M172
M19021
M19121
M19221
M1992
N5234
R160
R7989
K7151
K760
M13112
M13162
M13842
M151
M1632
M1731
M19022
M19122
M19222
M1993
N5239
R161
R799
K730
K7689
M13121
M13171
M13851
M152
M164
M1732
M19031
M19131
M19231
N500
N529
R162
K738
K769
M13122
M13172
M13852
M153
M1651
M174
M19032
M19132
M19232
N5201
N910
R180
E0840,
E0865
E0865,
E08351
E0865,
E0851
E0865,
E0936
E1011,
E10641
E1065,
E1022
E1065,
E1041
E1121,
E1165
E1165,
E11329
E0851,
E0865
E0865,
E08359
E0865,
E0852
E0865,
E0940
E1021,
E1065
E1065,
E1029
E1065,
E1042
E11311,
E1165
E1165,
E11331
E0865,
E08311
E0865,
E0836
E0865,
E0859
E0865,
E0951
E10311,
E1065
E1065,
E10321
E1065,
E1043
E11319,
E1165
E1165,
E11339
E0865,
E08319
E0865,
E0839
E0865,
E0869
E0865,
E0969
E10319,
E1065
E1065,
E10329
E1065,
E1044
E1136,
E1165
E1165,
E11341
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
E0801,
E0810,
E0821,
E08311, E08319, E0836,
E0865
E0865
E0865
E0865
E0865
E0865
E0865,
E0865,
E0865,
E0865,
E0865,
E0865,
E08321
E08329
E08331
E08339
E08341
E08349
E0865,
E0865,
E0865,
E0865,
E0865,
E0865,
E0840
E0841
E0842
E0843
E0844
E0849
E0865,
E0865,
E0865,
E0865,
E0865,
E0865,
E088
E0901
E0910
E0921
E09311
E09319
E0865,
E0865,
E0865,
E0865,
E1010,
E1011,
E098
E1310
E1365
E138
E1065
E1065
E1036,
E1039,
E1040,
E1051,
E1065,
E1065,
E1065
E1065
E1065
E1065
E1069
E108
E1065,
E1065,
E1065,
E1065,
E1065,
E1065,
E10331
E10339
E10341
E10349
E10351
E10359
E1065,
E1065,
E1065,
E1065,
E1100,
E1101,
E1049
E10610
E1052
E1059
E1165
E1165
E1139,
E1140,
E1151,
E1165,
E1165,
E1165,
E1165
E1165
E1165
E1169
E118
E11321
E1165,
E1165,
E1165,
E1321,
E11349
E11351
E11359
E0865
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual Radiology and Laboratory Services Handbook, subsection
2.2.9, “Iron Studies,” for additional information.
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Lung Volume Reduction Surgery
Preoperative pulmonary rehabilitation services procedure codes G0302, G0303, G0304 and postdischarge
pulmonary surgery services procedure code G0305 may be reimbursed when they are submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
J430
J431
J432
J438
J983
Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook,
subsection 4.2.15, “Lung Volume Reduction Surgery (LVRS);” and the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.42, “Lung Volume Reduction Surgery
(LVRS),” for additional information.
Mastectomy and Breast Reconstruction
Mastectomy and breast reconstruction procedures are limited to the following diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C50011
C50012
C50021
C50022
C50111
C50112
C50121
C50211
C50212
C50221
C50222
C50311
C50312
C50321
C50411
C50412
C50421
C50422
C50511
C50512
C50521
C50611
C50612
C50621
C50622
C50811
C50812
C50821
C50921
C50922
C7981
D0501
D0502
D0511
D0512
D0582
C50122
C50322
C50522
C50822
D0581
The following ICD-10-CM diagnosis codes are a benefit of Texas Medicaid for simple, subcutaneous, radical, and
modified radical mastectomies and for all breast reconstruction procedures:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z1501
Z803
Z853
Z9011
Z9012
Z9013
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.43, “Mastectomy and Breast Reconstruction,” for additional information.
Neurostimulators
Some benefit criteria for neurostimulators will change. Neurostimulators are a benefit of Texas Medicaid when
medically necessary. Neurostimulators procedures and the rental of devices and associated supplies, such as leads
and form fitting conductive garments are a benefit of Texas Medicaid.
Sacral Nerve Stimulators (SNS)
The surgical implantation of an SNS and purchase of a device may be considered for prior authorization for clients with:
• Urinary incontinence secondary to urethral instability and/or detrusor muscle instability.
• Chronic voiding dysfunction.
• Non-obstructive urinary retention.
• Fecal incontinence.
Vagal Nerve Stimulators (VNS)
The surgical implantation of a VNS and purchase of a device (procedure code L8686 TG when submitted for
durable medical equipment [other or purchased new] services) may be considered for prior authorization for clients
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Medicaid Fee-For-Service and Managed Care Providers
with partial onset intractable seizures when there is failure, contraindication, or intolerance to all suitable medical
and pharmacological management.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.44.12, “Sacral Nerve Stimulators (SNS);” subsection 9.2.44 “Neurostimulators;” and subsection 9.2.44.13, “Vagal Nerve Stimulators (VNS),” for additional information.
Obstetric Services
Providers must submit claims for obstetric services procedure codes with the most appropriate ICD-10-CM
diagnosis codes as indicated below. Procedure code J1725 may be reimbursed when submitted with the following
ICD-10-CM diagnosis code:
Diagnosis Code (Submitted as stand-alone diagnosis code)
O09211
Procedure codes 99460 or 99463 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
P002
P003
P0089
P009
Z372
Z373
Z374
Z3751
Z3752
Z3753
Z3754
Z3759
Z3761
Z3762
Z3763
Z3764
Z3769
Z377
Z3800
Z381
Z3830
Z384
Z3861
Z3862
Z3863
Z3864
Z3865
Z3866
Z3868
Z3869
Z387
Procedure codes 99406 or 99407 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O99330
O99331
O99332
O99333
O99334
O99335
Procedure code 82731 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O4700
O4702
O4703
O479
Procedure codes 36460, 59012, or 76941 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O353XX0
O353XX1
O353XX2
O353XX3
O353XX4
O353XX5
O353XX9
O358XX0
O360110
O360111
O360112
O360113
O360114
O360115
O360119
O360120
O360121
O360122
O360123
O360124
O360125
O360129
O360130
O360131
O360132
O360133
O360134
O360135
O360139
O360190
O360191
O360192
O360193
O360194
O360195
O360199
O360910
O360911
O360912
O360913
O360914
O360915
O360919
O360920
O360921
O360922
O360923
O360924
O360925
O360929
O360930
O360931
O360932
O360933
O360934
O360935
O360939
O360990
O360991
O360992
O360993
O360994
O360995
O360999
O361110
O361111
O361112
O361113
O361114
O361115
O361119
O361120
O361121
O361122
O361123
O361124
O361125
O361129
O361130
O361131
O361132
O361133
O361134
O361135
O361139
O361190
O361191
O361192
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O361193
O361194
O361195
O361199
O361910
O361914
O361915
O361919
O361920
O361921
O361925
O361929
O361930
O361931
O361932
O361939
O361990
O361991
O361992
O361993
O368210
O368211
O368212
O368213
O368214
O368221
O368222
O368223
O368224
O368225
O368232
O368233
O368234
O368235
O368239
O368293
O368294
O368295
O368299
O4690
O361911
O361922
O361933
O361994
O368215
O368229
O368290
O4691
O361912
O361923
O361934
O361995
O368219
O368230
O368291
O4692
O361913
O361924
O361935
O361999
O368220
O368231
O368292
O4693
Procedure code 59001 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O401XX0
O401XX1
O401XX2
O401XX3
O401XX4
O401XX5
O401XX9
O402XX0
O402XX1
O402XX2 O402XX3 O402XX4
O402XX5
O402XX9
O403XX0
O403XX1
O403XX3
O403XX4
O403XX5
O403XX9
O409XX0
O409XX1
O409XX2
O403XX2
O409XX5
O409XX9
O409XX3
O409XX4
Procedure codes 59070, 59074, or 59076 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O360110
O360111
O360112
O360113
O360114
O360115
O360119
O360120
O360121
O360122
O360123
O360124
O360125
O360129
O360130
O360131
O360132
O360133
O360134
O360135
O360139
O360190
O360191
O360192
O360193
O360194
O360195
O360199
O360910
O360911
O360912
O360913
O360914
O360915
O360919
O360920
O360921
O360922
O360923
O360924
O360925
O360929
O360930
O360931
O360932
O360933
O360934
O360935
O360939
O360990
O360991
O360992
O360993
O360994
O360995
O360999
O361110
O361111
O361112
O361113
O361114
O361115
O361119
O361120
O361121
O361122
O361123
O361124
O361125
O361129
O361130
O361131
O361132
O361133
O361134
O361135
O361139
O361190
O361191
O361192
O361193
O361194
O361195
O361199
O361910
O361911
O361912
O361913
O361914
O361915
O361919
O361920
O361921
O361922
O361923
O361924
O361925
O361929
O361930
O361931
O361932
O361933
O361934
O361935
O361939
O361990
O361991
O361992
O361993
O361994
O361995
O361999
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 9.2.47.2,
“Hospital Visits and Routine Care;” subsection 9.2.48.10, “Tobacco Use Cessation Counseling;” subsection 9.2.48.4, “Fetal Fibronectin;” subsection 9.2.48.5, “Fetal Intrauterine Transfusion (FIUT);” subsection 9.2.48.1, “Amniocentesis, Cordocentesis, and Ultrasonic Guidance;” and subsection 9.2.48.11,
“Transabdominal Amnioinfusion,” for additional information.
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Medicaid Fee-For-Service and Managed Care Providers
Otology and Audiometry Services
Acoustic reflex testing procedure code 92568 may be reimbursed when it is submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D333
G510
G511
G518
G519
H8001
H8002
H8003
H8011
H8012
H8013
H8021
H8022
H8023
H8081
H8082
H8083
H8091
H8092
H8093
H8101
H8102
H8103
H8111
H8112
H8113
H8121
H8122
H8123
H81311
H81312
H81313
H81319
H81391
H81392
H81393
H8141
H8142
H8143
H818X1
H818X2
H818X3
H8191
H8192
H8193
H8301
H8302
H8303
H8311
H8312
H8313
H832X1
H832X2
H832X3
H838X1
H838X2
H838X3
H838X9
H8391
H8392
H8393
H900
H9011
H9012
H902
H903
H9041
H9042
H905
H906
H9071
H9072
H908
H9101
H9102
H9103
H9121
H9122
H9123
H918X1
H918X2
H918X3
H9191
H9192
H9193
H9311
H9312
H9313
H93211
H93212
H93213
H93221
H93222
H93223
H93231
H93232
H93233
H93241
H93242
H93243
H93291
H93292
H93293
H933X1
H933X2
H933X3
H933X9
Q179
R42
Refer to: The Texas Medicaid Provider Procedures Manual Vision and Hearing Services Handbook, subsection 2.2.3.5,
“Limitations,” for additional information.
Pediatric Pneumogram
Pediatric pneumogram procedure codes may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes for clients who are birth through 11 months of age:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
K200
K208
K209
K210
K219
K220
P220
P228
P270
P271
P278
P282
P283
P284
P285
P2881
P2889
P84
R0600
R0609
R062
R063
R0681
R0682
R0683
R0689
R6813
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physician, and Physician
Assistants Handbook, subsection 9.2.26.10, “Pediatric Pneumogram,” for additional information.
Physician Evaluation and Management Services
Preventive Care Visits
Only one preventive care visit (procedure code 99385, 99386, 99387, 99395, 99396, or 99397) may be considered
for reimbursement each rolling year, any provider. Providers must bill the preventive services with ICD-10-CM
diagnosis code Z0000, Z0001, Z01411, or Z01419.
Laboratory Services, Immunizations and Diagnostic Screenings
Laboratory services, immunizations, and diagnostic screenings recommended by the U.S. Preventive Services Task
Force (USPSTF) may be reimbursed using the most accurate ICD-10-CM diagnosis code that represents the client’s
condition. Diagnosis code Z0000 or Z0001 may each be used once per rolling year for each screen if no other
diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.
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Medicaid Fee-For-Service and Managed Care Providers
Concurrent Care
Concurrent care will not be paid to providers of the same specialty for the same or related diagnoses. A diagnosis
will be considered related when up to six digits match the primary ICD-10-CM diagnosis code. Denied concurrent
care will be considered on appeal when accompanied by documentation of medical necessity.
Group Clinical Visits
Group clinical visits may be reimbursed for the management of the conditions of diabetes, asthma, or pregnancy.
Group clinical visit procedure codes may be reimbursed when they are submitted with one of the following ICD-10
diagnosis codes:
Diabetes Diagnosis Codes
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E1010
E1011
E1021
E1022
E1029
E10329
E10331
E10339
E10341
E10349
E1040
E1041
E1042
E1043
E1039
E10620
E10610
E10618
E1052
E1059
E10630
E10638
E10641
E10649
E1065
E1101
E1121
E1122
E1129
E11311
E11331
E11339
E11341
E11349
E11351
E1140
E1141
E1142
E1143
E1144
E1159
E11610
E11641
E1169
E118
E1311
E1321
E1322
E1329
E13311
E13331
E13339
E13341
E13349
E13351
E1340
E1341
E1342
E1343
E1344
E1359
E13610
E13641
E138
E139
E10311
E10351
E1044
E10621
E1069
E11319
E11359
E1149
E119
E13319
E13359
E1349
E10319
E10359
E1049
E10622
E108
E11321
E1136
E1151
E1301
E13321
E1336
E1351
E10321
E1036
E1051
E10628
E109
E11329
E1139
E1152
E1310
E13329
E1339
E1352
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
E1010,
E1011,
E1011,
E1021,
E1022,
E1029,
E1065
E10641
E1065
E1065
E1065
E1065
E10331, E1036,
E1039,
E10339, E10341, E10349,
E1065
E1065
E1065
E1065
E1065
E1065
E1059,
E10610, E1140,
E1040,
E1041,
E1042,
E1065
E1065
E1165
E1065
E1065
E1065
E1065,
E1100,
E1101,
E1121,
E11311,
E11319,
E108
E1165
E1165
E1165
E1165
E1165
E1165,
E13319,
E13321, E13329, E13331, E1336,
E118
E1165
E1165
E1165
E1165
E1165
E13351,
E13359,
E1165
E1165
E10311,
E1065
E10351,
E1065
E1043,
E1065
E1136,
E1165
E1339,
E1165
E10319,
E1065
E10359,
E1065
E1044,
E1065
E1139,
E1165
E13339,
E1165
E10321,
E1065
E1051,
E1065
E1049,
E1065
E1151,
E1165
E13341,
E1165
E10329,
E1065
E1052,
E1065
E1065,
E1069
E1165,
E1169
E13349,
E1165
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
ICD-10 Special Bulletin, No. 8
52
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Asthma Diagnosis Codes
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
J440
J441
J449
J4520
J4521
J4522
J4541
J4542
J4550
J4551
J4552
J45901
J45998
J4530
J45902
J4531
J45909
J4532
J45990
J4540
J45991
Pregnancy-related Diagnosis Codes
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
O0901
O0902
O0903
O0911
O0912
O09213
O09291
O09292
O09293
O0931
O0942
O0943
O09511
O09512
O09513
O09611
O09612
O09613
O09621
O09622
O0973
O09811
O09812
O09813
O09821
O09892
O09893
O0991
O0992
O0993
Z3403
Z3481
Z3482
Z3483
O0913
O0932
O09521
O09623
O09822
Z331
O09211
O0933
O09522
O0971
O09823
Z3401
O09212
O0941
O09523
O0972
O09891
Z3402
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.61.4, “Group Clinical Visits;” subsection 9.2.61.1, “Office or Other
Outpatient Hospital Services;” and subsection 9.2.61.6, “Inpatient Hospital Services,” for additional
information.
Prognostic Breast and Gynecological Cancer Studies
Procedure codes 84233, 84234, 88360, and 88361 may be reimbursed when they are submitted with one of the
following ICD-10-CM diagnosis codes for breast or uterine cancer as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C50011
C50012
C50021
C50022
C50111
C50112
C50121
C50122
C50211
C50212
C50221
C50222
C50311
C50312
C50321
C50322
C50411
C50412
C50421
C50422
C50511
C50512
C50521
C50522
C50611
C50612
C50621
C50622
C50811
C50812
C50821
C50822
C50921
C50922
C540
C541
C542
C543
C548
C792
C7981
D0501
D0502
D0511
D0512
D0581
D0582
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.17, “Prognostic Breast and Gynecological Cancer Studies,” for
additional information.
Pulmonary Function Studies
High Altitude Simulation Test (HAST) procedure codes 94452 and 94453 must be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8411
E8419
E848
E849
I270
I271
I272
I2781
I2789
I279
J410
J411
J418
J42
J430
J431
J432
J438
J439
J440
J441
J449
J471
J479
J60
J700
J701
J708
J709
J82
J8401
J8402
J8403
J8409
J8410
J849
J9610
J9611
J9612
ICD-10 Special Bulletin, No. 8
53
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
J982
P270
P271
P278
Q332
Q334
Q336
When Billing HAST procedure codes 94452 and 94453 with one of the following ICD-10-CM diagnosis codes
listed below, evidence of hypoxemia must be documented in the client’s medical record:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8419
E848
E849
I270
I271
I272
I2781
I2789
I279
J410
J411
J418
J42
J430
J431
J432
J438
J439
J440
J441
J449
J471
J479
J60
J700
J708
J709
J82
P270
P271
P278
Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Handbook, subsection
4.2.19.4, “Pulmonary Function Studies,” for additional information.
Rabies Post Exposure Treatment
Postexposure rabies vaccine procedure codes 90375, 90376, and 90675 may be reimbursed when they are submitted
with the following ICD-10-CM diagnosis code:
Diagnosis Code (Submitted as stand-alone diagnosis code)
Z203
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.38, “Postexposure Prophylaxis for Rabies,” for additional information.
Renal Dialysis Services
Renal dialysis services for acute renal failure and end-stage renal disease (ESRD) may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
N170
N171
N172
N178
N179
N181
N182
N183
N184
N185
N186
N189
Procedure code G0257 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
N185
N186
Refer to: The Texas Medicaid Provider Procedures Manual Clinics and Other Outpatient Facility Services Handbook,
subsection 6.2.4, “Facility Revenue Codes;” and subsection 6.2.1.1, “Unscheduled or Emergency Dialysis
in a Non-Certified ESRD Facility,” for additional information.
Skin Therapy
Procedure codes 11900 and 11901 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B070
B081
B550
B551
B552
L401
L402
L403
L404
L4050
ICD-10 Special Bulletin, No. 8
54
B559
L4051
D863
L4052
L400
L4053
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
L4054
L4059
L408
L410
L411
L415
L418
L42
L440
L700
L704
L705
L708
L710
L711
L910
L928
T2000XA
T2000XD
T2000XS
T20012A
T20012D
T20012S
T2002XA
T2002XD
T2003XS
T2004XA
T2004XD
T2004XS
T2005XA
T2006XD
T2006XS
T2007XA
T2007XD
T2007XS
T2010XA
T2010XD
T2010XS
T20111A
T20111D
T20112S
T2012XA
T2012XD
T2012XS
T2013XA
T2014XD
T2014XS
T2015XA
T2015XD
T2015XS
T2017XA
T2017XD
T2017XS
T2019XA
T2019XD
T2020XS
T20211A
T20211D
T20211S
T20212A
T2022XD
T2022XS
T2023XA
T2023XD
T2023XS
T2025XA
T2025XD
T2025XS
T2026XA
T2026XD
T2027XS
T2029XA
T2029XD
T2029XS
T2030XA
T20311D
T20311S
T20312A
T20312D
T20312S
T2033XA
T2033XD
T2033XS
T2034XA
T2034XD
T2035XS
T2036XA
T2036XD
T2036XS
T2037XA
T2039XD
T2039XS
T2040XA
T2040XD
T2040XS
T20412A
T20412D
T20412S
T2042XA
T2042XD
T2043XS
T2044XA
T2044XD
T2044XS
T2045XA
T2046XD
T2046XS
T2047XA
T2047XD
T2047XS
T2050XA
T2050XD
T2050XS
T20511A
T20511D
T20512S
T2052XA
T2052XD
T2052XS
T2053XA
T2054XD
T2054XS
T2055XA
T2055XD
T2055XS
T2057XA
T2057XD
T2057XS
T2059XA
T2059XD
T2060XS
T20611A
T20611D
T20611S
T20612A
T2062XD
T2062XS
T2063XA
T2063XD
T2063XS
T2065XA
T2065XD
T2065XS
T2066XA
T2066XD
T2067XS
T2069XA
T2069XD
T2069XS
T2070XA
T20711D
T20711S
T20712A
T20712D
T20712S
T2073XA
T2073XD
T2073XS
T2074XA
T2074XD
T2075XS
T2076XA
T2076XD
T2076XS
T2077XA
T2079XD
T2079XS
T2100XA
T2100XD
T2100XS
T2102XA
T2102XD
T2102XS
T2103XA
T2103XD
T2104XS
T2106XA
T2106XD
T2106XS
T2107XA
T2110XD
T2110XS
T2111XA
T2111XD
T2111XS
T2113XA
T2113XD
T2113XS
T2114XA
T2114XD
T2116XS
T2117XA
T2117XD
T2117XS
T2119XA
ICD-10 Special Bulletin, No. 8
55
L412
L701
L718
T20011A
T2002XS
T2005XD
T2009XA
T20111S
T2013XD
T2016XA
T2019XS
T20212D
T2024XA
T2026XS
T2030XD
T2032XA
T2034XS
T2037XD
T20411A
T2042XS
T2045XD
T2049XA
T20511S
T2053XD
T2056XA
T2059XS
T20612D
T2064XA
T2066XS
T2070XD
T2072XA
T2074XS
T2077XD
T2101XA
T2103XS
T2107XD
T2112XA
T2114XS
T2119XD
L413
L702
L730
T20011D
T2003XA
T2005XS
T2009XD
T20112A
T2013XS
T2016XD
T2020XA
T20212S
T2024XD
T2027XA
T2030XS
T2032XD
T2035XA
T2037XS
T20411D
T2043XA
T2045XS
T2049XD
T20512A
T2053XS
T2056XD
T2060XA
T20612S
T2064XD
T2067XA
T2070XS
T2072XD
T2075XA
T2077XS
T2101XD
T2104XA
T2107XS
T2112XD
T2116XA
T2119XS
L414
L703
L732
T20011S
T2003XD
T2006XA
T2009XS
T20112D
T2014XA
T2016XS
T2020XD
T2022XA
T2024XS
T2027XD
T20311A
T2032XS
T2035XD
T2039XA
T20411S
T2043XD
T2046XA
T2049XS
T20512D
T2054XA
T2056XS
T2060XD
T2062XA
T2064XS
T2067XD
T20711A
T2072XS
T2075XD
T2079XA
T2101XS
T2104XD
T2110XA
T2112XS
T2116XD
T2120XA
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T2120XD
T2120XS
T2121XA
T2121XD
T2121XS
T2123XA
T2123XD
T2123XS
T2124XA
T2124XD
T2126XS
T2127XA
T2127XD
T2127XS
T2130XA
T2131XD
T2131XS
T2132XA
T2132XD
T2132XS
T2134XA
T2134XD
T2134XS
T2136XA
T2136XD
T2137XS
T2140XA
T2140XD
T2140XS
T2141XA
T2142XD
T2142XS
T2143XA
T2143XD
T2143XS
T2146XA
T2146XD
T2146XS
T2147XA
T2147XD
T2150XS
T2151XA
T2151XD
T2151XS
T2152XA
T2153XD
T2153XS
T2154XA
T2154XD
T2154XS
T2157XA
T2157XD
T2157XS
T2159XA
T2159XD
T2160XS
T2161XA
T2161XD
T2161XS
T2162XA
T2163XD
T2163XS
T2164XA
T2164XD
T2164XS
T2167XA
T2167XD
T2167XS
T2170XA
T2170XD
T2171XS
T2172XA
T2172XD
T2172XS
T2173XA
T2174XD
T2174XS
T2176XA
T2176XD
T2176XS
T2200XA
T2200XD
T2200XS
T22011A
T22011D
T22012S
T22021A
T22021D
T22021S
T22022A
T22031D
T22031S
T22032A
T22032D
T22032S
T22042A
T22042D
T22042S
T22049D
T22051A
T22052D
T22052S
T22061A
T22061D
T22061S
T22091A
T22091D
T22091S
T22092A
T22092D
T2210XS
T22111A
T22111D
T22111S
T22112A
T22121D
T22121S
T22122A
T22122D
T22122S
T22132A
T22132D
T22132S
T22141A
T22141D
T22142S
T22151A
T22151D
T22151S
T22152A
T22161D
T22161S
T22162A
T22162D
T22162S
T22192A
T22192D
T22192S
T2220XA
T2220XD
T22211S
T22212A
T22212D
T22212S
T22221A
T22222D
T22222S
T22231A
T22231D
T22231S
T22239D
T22241A
T22241D
T22241S
T22242A
T22251A
T22251D
T22251S
T22252A
T22252D
T22261S
T22262A
T22262D
T22262S
T22291A
T22292D
T22292S
T2230XA
T2230XD
T2230XS
T22312A
T22312D
T22312S
T22321A
T22321D
T22322S
T22331A
T22331D
T22331S
T22332A
T22341D
T22341S
T22342A
T22342D
T22342S
T22352A
T22352D
T22352S
T22361A
T22361D
T22362S
T22369D
T22391A
T22391D
T22391S
ICD-10 Special Bulletin, No. 8
56
T2122XA
T2124XS
T2130XD
T2133XA
T2136XS
T2141XD
T2144XA
T2147XS
T2152XD
T2156XA
T2159XS
T2162XD
T2166XA
T2170XS
T2173XD
T2177XA
T22011S
T22022D
T22041A
T22051D
T22062A
T22092S
T22112D
T22131A
T22141S
T22152D
T22191A
T2220XS
T22221D
T22232A
T22242D
T22252S
T22291D
T22311A
T22321S
T22332D
T22351A
T22361S
T22392A
T2122XD
T2126XA
T2130XS
T2133XD
T2137XA
T2141XS
T2144XD
T2150XA
T2152XS
T2156XD
T2160XA
T2162XS
T2166XD
T2171XA
T2173XS
T2177XD
T22012A
T22022S
T22041D
T22051S
T22062D
T2210XA
T22112S
T22131D
T22142A
T22152S
T22191D
T22211A
T22221S
T22232D
T22242S
T22261A
T22291S
T22311D
T22322A
T22332S
T22351D
T22362A
T22392D
T2122XS
T2126XD
T2131XA
T2133XS
T2137XD
T2142XA
T2144XS
T2150XD
T2153XA
T2156XS
T2160XD
T2163XA
T2166XS
T2171XD
T2174XA
T2177XS
T22012D
T22031A
T22041S
T22052A
T22062S
T2210XD
T22121A
T22131S
T22142D
T22161A
T22191S
T22211D
T22222A
T22232S
T22249D
T22261D
T22292A
T22311S
T22322D
T22341A
T22351S
T22362D
T22392S
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T2240XA
T2240XD
T2240XS
T22411A
T22411D
T22412S
T22421A
T22421D
T22421S
T22422A
T22431D
T22431S
T22432A
T22432D
T22432S
T22442A
T22442D
T22442S
T22451A
T22451D
T22452S
T22461A
T22461D
T22461S
T22462A
T22491D
T22491S
T22492A
T22492D
T22492S
T22511A
T22511D
T22511S
T22512A
T22512D
T22521S
T22522A
T22522D
T22522S
T22531A
T22532D
T22532S
T22541A
T22541D
T22541S
T22551A
T22551D
T22551S
T22552A
T22552D
T22561S
T22562A
T22562D
T22562S
T22591A
T22592D
T22592S
T2260XA
T2260XD
T2260XS
T22612A
T22612D
T22612S
T22621A
T22621D
T22622S
T22631A
T22631D
T22631S
T22632A
T22641D
T22641S
T22642A
T22642D
T22642S
T22651S
T22652A
T22652D
T22652S
T22661A
T22662D
T22662S
T22691A
T22691D
T22691S
T2270XA
T2270XD
T2270XS
T22711A
T22711D
T22712S
T22721A
T22721D
T22721S
T22722A
T22731D
T22731S
T22732A
T22732D
T22732S
T22742A
T22742D
T22742S
T22751A
T22751D
T22752S
T22761A
T22761D
T22761S
T22762A
T22791D
T22791S
T22792A
T22792D
T22792S
T23002A
T23002D
T23002S
T23011A
T23011D
T23012S
T23021A
T23021D
T23021S
T23022A
T23031D
T23031S
T23032A
T23032D
T23032S
T23042A
T23042D
T23042S
T23051A
T23051D
T23052S
T23061A
T23061D
T23061S
T23062A
T23071D
T23071S
T23072A
T23072D
T23072S
T23092A
T23092D
T23092S
T23101A
T23101D
T23102S
T23111A
T23111D
T23111S
T23112A
T23121D
T23121S
T23122A
T23122D
T23122S
T23132A
T23132D
T23132S
T23141A
T23141D
T23142S
T23151A
T23151D
T23151S
T23152A
T23161D
T23161S
T23162A
T23162D
T23162S
T23172A
T23172D
T23172S
T23191A
T23191D
T23192S
T23201A
T23201D
T23201S
T23202A
T23211D
T23211S
T23212A
T23212D
T23212S
T23222A
T23222D
T23222S
T23231A
T23231D
ICD-10 Special Bulletin, No. 8
57
T22411S
T22422D
T22441A
T22451S
T22462D
T2250XA
T22512S
T22531D
T22542A
T22552S
T22591D
T22611A
T22621S
T22632D
T22649D
T22661D
T22692A
T22711S
T22722D
T22741A
T22751S
T22762D
T23001A
T23011S
T23022D
T23041A
T23051S
T23062D
T23091A
T23101S
T23112D
T23131A
T23141S
T23152D
T23171A
T23191S
T23202D
T23221A
T23231S
T22412A
T22422S
T22441D
T22452A
T22462S
T2250XD
T22521A
T22531S
T22542D
T22561A
T22591S
T22611D
T22622A
T22632S
T22651A
T22661S
T22692D
T22712A
T22722S
T22741D
T22752A
T22762S
T23001D
T23012A
T23022S
T23041D
T23052A
T23062S
T23091D
T23102A
T23112S
T23131D
T23142A
T23152S
T23171D
T23192A
T23202S
T23221D
T23232A
T22412D
T22431A
T22441S
T22452D
T22491A
T2250XS
T22521D
T22532A
T22542S
T22561D
T22592A
T22611S
T22622D
T22641A
T22651D
T22662A
T22692S
T22712D
T22731A
T22741S
T22752D
T22791A
T23001S
T23012D
T23031A
T23041S
T23052D
T23071A
T23091S
T23102D
T23121A
T23131S
T23142D
T23161A
T23171S
T23192D
T23211A
T23221S
T23232D
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T23232S
T23241A
T23241D
T23241S
T23242A
T23251D
T23251S
T23252A
T23252D
T23252S
T23262A
T23262D
T23262S
T23271A
T23271D
T23272S
T23291A
T23291D
T23291S
T23292A
T23301D
T23301S
T23302A
T23302D
T23302S
T23312A
T23312D
T23312S
T23321A
T23321D
T23322S
T23331A
T23331D
T23331S
T23332A
T23341D
T23341S
T23342A
T23342D
T23342S
T23352A
T23352D
T23352S
T23361A
T23361D
T23362S
T23371A
T23371D
T23371S
T23372A
T23391D
T23391S
T23392A
T23392D
T23392S
T23402A
T23402D
T23402S
T23411A
T23411D
T23412S
T23421A
T23421D
T23421S
T23422A
T23431D
T23431S
T23432A
T23432D
T23432S
T23442A
T23442D
T23442S
T23451A
T23451D
T23452S
T23461A
T23461D
T23461S
T23462A
T23471D
T23471S
T23472A
T23472D
T23472S
T23492A
T23492D
T23492S
T23501A
T23501D
T23502S
T23511A
T23511D
T23511S
T23512A
T23521D
T23521S
T23522A
T23522D
T23522S
T23532A
T23532D
T23532S
T23541A
T23541D
T23542S
T23551A
T23551D
T23551S
T23552A
T23561D
T23561S
T23562A
T23562D
T23562S
T23572A
T23572D
T23572S
T23591A
T23591D
T23592S
T23601A
T23601D
T23601S
T23602A
T23611D
T23611S
T23612A
T23612D
T23612S
T23622A
T23622D
T23622S
T23631A
T23631D
T23632S
T23641A
T23641D
T23641S
T23642A
T23651D
T23651S
T23652A
T23652D
T23652S
T23662A
T23662D
T23662S
T23671A
T23671D
T23672S
T23691A
T23691D
T23691S
T23692A
T23701D
T23701S
T23702A
T23702D
T23702S
T23712A
T23712D
T23712S
T23721A
T23721D
T23722S
T23731A
T23731D
T23731S
T23732A
T23741D
T23741S
T23742A
T23742D
T23742S
T23752A
T23752D
T23752S
T23761A
T23761D
T23762S
T23771A
T23771D
T23771S
T23772A
T23791D
T23791S
T23792A
T23792D
T23792S
T24002A
T24002D
T24002S
T24011A
T24011D
ICD-10 Special Bulletin, No. 8
58
T23242D
T23261A
T23271S
T23292D
T23311A
T23321S
T23332D
T23351A
T23361S
T23372D
T23401A
T23411S
T23422D
T23441A
T23451S
T23462D
T23491A
T23501S
T23512D
T23531A
T23541S
T23552D
T23571A
T23591S
T23602D
T23621A
T23631S
T23642D
T23661A
T23671S
T23692D
T23711A
T23721S
T23732D
T23751A
T23761S
T23772D
T24001A
T24011S
T23242S
T23261D
T23272A
T23292S
T23311D
T23322A
T23332S
T23351D
T23362A
T23372S
T23401D
T23412A
T23422S
T23441D
T23452A
T23462S
T23491D
T23502A
T23512S
T23531D
T23542A
T23552S
T23571D
T23592A
T23602S
T23621D
T23632A
T23642S
T23661D
T23672A
T23692S
T23711D
0T23722A
T23732S
T23751D
T23762A
T23772S
T24001D
T24012A
T23251A
T23261S
T23272D
T23301A
T23311S
T23322D
T23341A
T23351S
T23362D
T23391A
T23401S
T23412D
T23431A
T23441S
T23452D
T23471A
T23491S
T23502D
T23521A
T23531S
T23542D
T23561A
T23571S
T23592D
T23611A
T23621S
T23632D
T23651A
T23661S
T23672D
T23701A
T23711S
T23722D
T23741A
T23751S
T23762D
T23791A
T24001S
T24012D
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T24012S
T24021A
T24021D
T24021S
T24022A
T24031D
T24031S
T24032A
T24032D
T24032S
T24092A
T24092D
T24092S
T24101A
T24101D
T24102S
T24111A
T24111D
T24111S
T24112A
T24121D
T24121S
T24122A
T24122D
T24122S
T24132A
T24132D
T24132S
T24191A
T24191D
T24192S
T24201A
T24201D
T24201S
T24202A
T24211D
T24211S
T24212A
T24212D
T24212S
T24222A
T24222D
T24222S
T24229D
T24231A
T24232D
T24232S
T24291A
T24291D
T24291S
T24301A
T24301D
T24301S
T24302A
T24302D
T24311S
T24312A
T24312D
T24312S
T24321A
T24322D
T24322S
T24331A
T24331D
T24331S
T24391A
T24391D
T24391S
T24392A
T24392D
T24401S
T24402A
T24402D
T24402S
T24411A
T24412D
T24412S
T24421A
T24421D
T24421S
T24431A
T24431D
T24431S
T24432A
T24432D
T24491S
T24492A
T24492D
T24492S
T24501A
T24502D
T24502S
T24511A
T24511D
T24511S
T24521A
T24521D
T24521S
T24522A
T24522D
T24531S
T24532A
T24532D
T24532S
T24591A
T24592D
T24592S
T24601A
T24601D
T24601S
T24611A
T24611D
T24611S
T24612A
T24612D
T24621S
T24622A
T24622D
T24622S
T24631A
T24632D
T24632S
T24691A
T24691D
T24691S
T24701A
T24701D
T24701S
T24702A
T24702D
T24711S
T24712A
T24712D
T24712S
T24721A
T24722D
T24722S
T24731A
T24731D
T24731S
T24791A
T24791D
T24791S
T24792A
T24792D
T25011S
T25012A
T25012D
T25012S
T25021A
T25022D
T25022S
T25031A
T25031D
T25031S
T25091A
T25091D
T25091S
T25092A
T25092D
T25111S
T25112A
T25112D
T25112S
T25121A
T25122D
T25122S
T25131A
T25131D
T25131S
T25191A
T25191D
T25191S
T25192A
T25192D
T25211S
T25212A
T25212D
T25212S
T25221A
T25222D
T25222S
T25231A
T25231D
T25231S
T25291A
T25291D
T25291S
T25292A
T25292D
T25311S
T25312A
T25312D
T25312S
T25321A
ICD-10 Special Bulletin, No. 8
59
T24022D
T24091A
T24101S
T24112D
T24131A
T24191S
T24202D
T24221A
T24231D
T24292A
T24302S
T24321D
T24332A
T24392S
T24411D
T24422A
T24432S
T24501D
T24512A
T24522S
T24591D
T24602A
T24612S
T24631D
T24692A
T24702S
T24721D
T24732A
T24792S
T25021D
T25032A
T25092S
T25121D
T25132A
T25192S
T25221D
T25232A
T25292S
T25321D
T24022S
T24091D
T24102A
T24112S
T24131D
T24192A
T24202S
T24221D
T24231S
T24292D
T24311A
T24321S
T24332D
T24401A
T24411S
T24422D
T24491A
T24501S
T24512D
T24531A
T24591S
T24602D
T24621A
T24631S
T24692D
T24711A
T24721S
T24732D
T25011A
T25021S
T25032D
T25111A
T25121S
T25132D
T25211A
T25221S
T25232D
T25311A
T25321S
T24031A
T24091S
T24102D
T24121A
T24131S
T24192D
T24211A
T24221S
T24232A
T24292S
T24311D
T24322A
T24332S
T24401D
T24412A
T24422S
T24491D
T24502A
T24512S
T24531D
T24592A
T24602S
T24621D
T24632A
T24692S
T24711D
T24722A
T24732S
T25011D
T25022A
T25032S
T25111D
T25122A
T25132S
T25211D
T25222A
T25232S
T25311D
T25322A
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T25322D
T25322S
T25331A
T25331D
T25331S
T25391A
T25391D
T25391S
T25392A
T25392D
T25411S
T25412A
T25412D
T25412S
T25421A
T25422D
T25422S
T25431A
T25431D
T25431S
T25491A
T25491D
T25491S
T25492A
T25492D
T25511S
T25512A
T25512D
T25512S
T25521A
T25522D
T25522S
T25531A
T25531D
T25531S
T25591A
T25591D
T25591S
T25592A
T25592D
T25611S
T25612A
T25612D
T25612S
T25621A
T25622D
T25622S
T25631A
T25631D
T25631S
T25711A
T25711D
T25711S
T25712A
T25712D
T25721S
T25722A
T25722D
T25722S
T25731A
T25732D
T25732S
T25791A
T25791D
T25791S
T2601XA
T2601XD
T2601XS
T2602XA
T2602XD
T2611XS
T2612XA
T2612XD
T2612XS
T2621XA
T2622XD
T2622XS
T2631XA
T2631XD
T2631XS
T2641XA
T2641XD
T2641XS
T2642XA
T2642XD
T2651XS
T2652XA
T2652XD
T2652XS
T2661XA
T2662XD
T2662XS
T2671XA
T2671XD
T2671XS
T2681XA
T2681XD
T2681XS
T2682XA
T2682XD
T2691XS
T2692XA
T2692XD
T2692XS
T271XXA
T275XXD T275XXS
T280XXA T280XXD T280XXS
T282XXA T282XXD T282XXS
T283XXA
T283XXD
T2840XS
T28411A
T28411D
T28411S
T28412A
T2849XD
T2849XS
T285XXA
T285XXD T285XXS
T287XXA T287XXD T287XXS
T288XXA T288XXD
T2890XS
T28911A
T28911D
T28911S
T28912A
T2899XD
T2899XS
T300
T304
T310
T3121
T3122
T3130
T3131
T3132
T3142
T3143
T3144
T3150
T3151
T3155
T3160
T3161
T3162
T3163
T3170
T3171
T3172
T3173
T3174
T3180
T3181
T3182
T3183
T3184
T3188
T3190
T3191
T3192
T3193
T3197
T3198
T3199
T320
T3210
T3222
T3230
T3231
T3232
T3233
T3243
T3244
T3250
T3251
T3252
T3260
T3261
T3262
T3263
T3264
T3271
T3272
T3273
T3274
T3275
ICD-10 Special Bulletin, No. 8
60
T25332A
T25392S
T25421D
T25432A
T25492S
T25521D
T25532A
T25592S
T25621D
T25632A
T25712S
T25731D
T25792A
T2602XS
T2621XD
T2632XA
T2642XS
T2661XD
T2672XA
T2682XS
T271XXD
T281XXA
T283XXS
T28412D
T286XXA
T288XXS
T28912D
T3110
T3133
T3152
T3164
T3175
T3185
T3194
T3211
T3240
T3253
T3265
T3276
T25332D
T25411A
T25421S
T25432D
T25511A
T25521S
T25532D
T25611A
T25621S
T25632D
T25721A
T25731S
T25792D
T2611XA
T2621XS
T2632XD
T2651XA
T2661XS
T2672XD
T2691XA
T271XXS
T281XXD
T2840XA
T28412S
T286XXD
T2890XA
T28912S
T3111
T3140
T3153
T3165
T3176
T3186
T3195
T3220
T3241
T3254
T3266
T3277
T25332S
T25411D
T25422A
T25432S
T25511D
T25522A
T25532S
T25611D
T25622A
T25632S
T25721D
T25732A
T25792S
T2611XD
T2622XA
T2632XS
T2651XD
T2662XA
T2672XS
T2691XD
T275XXA
T281XXS
T2840XD
T2849XA
T286XXS
T2890XD
T2899XA
T3120
T3141
T3154
T3166
T3177
T3187
T3196
T3221
T3242
T3255
T3270
T3280
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T3281
T3282
T3283
T3284
T3285
T3290
T3291
T3292
T3293
T3294
T3298
T3299
T3286
T3295
T3287
T3296
T3288
T3297
Procedure codes 96900, 96910, 96912, 96913, 96920, 96921, and 96922 may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A672
B070
B081
B550
B551
B552
B559
C8401
C8402
C8403
C8404
C8405
C8406
C8407
C8408
C8409
H02731 H02732 H02734 H02735
L100
L101
L102
L103
L104
L105
L1081
L1089
L120
L121
L122
L128
L130
L131
L138
L139
L200
L2081
L2082
L2083
L2084
L2089
L210
L211
L218
L219
L22
L230
L231
L232
L233
L235
L236
L237
L2381
L240
L241
L242
L243
L244
L245
L246
L247
L2481
L270
L271
L272
L278
L279
L300
L301
L302
L303
L304
L305
L400
L401
L402
L403
L404
L4050
L4051
L4052
L4053
L4054
L4059
L408
L410
L411
L412
L413
L414
L415
L418
L42
L440
L560
L561
L562
L563
L564
L565
L570
L571
L572
L573
L574
L575
L580
L581
L700
L701
L702
L703
L704
L705
L708
L710
L711
L718
L730
L80
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.68, “Skin Therapy,” for additional information.
Sleep Studies
Actigraphy procedure code 95803 may be reimbursed when submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F5104
F5105
F5113
G2581
G4700
G4701
G4709
G4710
G4711
G4712
G4713
G4714
G4719
G4720
G4721
G4722
G4723
G4724
G4725
G4726
G4727
G4729
G4761
Multiple sleep latency test (MSLT) procedure code 95805 may be reimbursed when submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E662
F5104
F5105
G2581
G4700
G4701
G4709
G4730
G47411
G47419
G47421 G47429 G4753
G4761
Pneumocardiogram procedure code 95807 may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G4731
G4733
G4734
G4735
G4736
G4737
P2911
P2912
R063
R0681
R0902
R230
ICD-10 Special Bulletin, No. 8
61
P282
R6813
P283
P284
P285
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Polysomnography procedure codes 95782, 95783, 95808, 95810, and 95811 may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E6601
E662
F10182
F10282
F10982
F11182
F11282
F11982
F13182
F13282
F13982
F14182
F14282
F14982
F15182
F15282
F15982
F19182
F19282
F19982
F5101
F5102
F5103
F5104
F5105
F5109
F5111
F5112
F5113
F5119
F513
F514
F515
F518
F519
G120
G121
G1221
G128
G2581
G373
G4700
G4701
G4710
G4711
G4712
G4713
G4719
G4720
G4721
G4722
G4723
G4724
G4725
G4726
G4727
G4729
G4730
G4731
G4732
G4733
G4734
G4735
G4736
G4737
G4739
G47411
G47419
G47421 G47429
G4750
G4751
G4752
G4753
G4754
G4759
G4761
G4762
G4763
G4769
G478
G479
G710
G712
G809
G8250
G901
G931
J353
J9610
J9611
J9612
N5201
N5202
N5203
Q040
Q041
Q042
Q078
Q308
Q311
Q312
Q313
Q315
Q318
Q320
Q321
Q322
Q323
Q324
Q672
Q673
Q674
Q750
Q751
Q752
Q753
Q754
Q755
Q758
Q759
Q770
Q771
Q773
Q774
Q775
Q777
Q778
Q779
Q781
Q789
Q870
R0681
R0902
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.69, “Sleep Studies,” for additional information.
Therapeutic Apheresis
Therapeutic apheresis with extracorporeal affinity column adsorption and plasma reinfusion may be considered
for reimbursement when billed for the low density lipoprotein (LDL) apheresis (such as Liposorber LA 15) or the
protein A immunoadsorption columns (such as Prosorba).
Therapeutic apheresis using the LDL apheresis column may be reimbursed for familial hypercholesterolemia
diagnosis code E780.
Procedure codes 36511, 36512, 36513, 36514, 36515, and 36516 may be reimbursed when they are submitted with
one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C880
C882
C883
C888
C9000
C9002
C9010
C9011
C9012
C9020
C9021
C9022
C9030
C9031
C9032
C9100
C9101
C9102
C9110
C9111
C9112
C9130
C9131
C9132
C9140
C9141
C9142
C9150
C9151
C9152
C9160
C9161
C9162
C9190
C9191
C9192
C91A0
C91A1
C91A2
C91Z0
C91Z1
C91Z2
C9200
C9201
C9202
C9210
C9211
C9212
C9220
C9221
C9222
C9230
C9231
C9232
C9240
C9241
C9242
C9250
C9251
C9252
C9260
C9261
C9262
C9290
C9291
C9292
C92A0
C92A1
C92A2
C92Z0
C92Z1
C92Z2
C9300
C9301
C9302
C9310
C9311
C9312
C9330
C9331
C9332
C9391
C9392
C93Z0
C93Z1
C93Z2
C9400
C9401
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C9402
C9420
C9421
C9422
C9430
C9441
C9442
C9480
C9481
C9482
C9510
C9511
C9512
C9590
C9591
D473
D474
D5700
D5701
D5702
D57212
D57219
D57412
D5780
D57811
D589
D590
D591
D592
D593
D65
D682
D68311
D6851
D6852
D6869
D688
D690
D691
D692
D6949
D696
D698
D699
D72828
D749
D750
D751
D7589
D759
D77
D890
D892
E0842
E0942
G603
G610
G6181
G6189
G620
G6282
G63
G64
G650
G7000
I010
I012
I018
I019
I773
K7200
K7201
K7581
K759
K760
K77
K8041
K8043
K8045
K8047
K8081
L100
L101
L102
L103
L1089
L109
L900
L940
L941
M05021
M05022
M05031
M05032
M05041
M05061
M05062
M05071
M05072
M0509
M05422
M05431
M05432
M05441
M05442
M05462
M05471
M05472
M0549
M05611
M05631
M05632
M05641
M05642
M05651
M05671
M05672
M0569
M069
M08011
M08031
M08032
M08041
M08042
M08051
M08071
M08072
M0809
M083
M08411
M08431
M08432
M08441
M08442
M08451
M08471
M08472
M0848
M08832
M08841
M08861
M08931
M08932
M08941
M08942
M08962
M310
M311
M320
M3210
M3301
M3302
M3309
M3310
M3311
M3321
M3322
M3329
M3390
M3391
M341
M342
M3481
M3482
M3483
N002
N003
N004
N005
N006
N011
N012
N013
N014
N015
N032
N034
N035
N037
N040
N047
N048
N049
N052
N054
N08
N171
N172
T8690
T8691
ICD-10 Special Bulletin, No. 8
63
C9431
C9500
C9592
D571
D57812
D594
D6859
D693
D732
D761
E1042
G621
G7001
I776
K762
K8061
L104
L943
M05042
M05411
M05451
M05612
M05652
M08012
M08052
M08412
M08452
M08842
M08951
M3219
M3312
M3392
M3489
N007
N016
N042
N055
T8692
C9432
C9501
D45
D5720
D57819
D599
D6861
D6941
D740
D762
E1142
G622
G731
I7789
K767
K8063
L105
M05011
M05051
M05412
M05452
M05621
M05661
M08021
M08061
M08421
M08461
M08851
M08952
M328
M3319
M3399
N000
N008
N017
N044
N058
T8693
C9440
C9502
D472
D57211
D588
D6182
D6862
D6942
D748
D763
E780
G6281
I00
K716
K7689
K8065
L1081
M05012
M05052
M05421
M05461
M05622
M05662
M08022
M08062
M08422
M08462
M08852
M08961
M3300
M3320
M340
N001
N010
N018
N045
N059
T8699
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, Section 9, “Physician;” subsection 9.2 “Services, Benefits, Limitations, and Prior
Authorization;” and subsection 9.2.73, “Therapeutic Apheresis,” for additional information.
Therapeutic Phlebotomy
Therapeutic phlebotomy procedure code 99195 may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D45
D649
D750
D751
E800
E801
E8020
E8021
E8029
E8310
E83110
E83118
E8319
P611
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.74, “Therapeutic Phlebotomy” for additional information.
Therapeutic Radiopharmaceuticals
Sodioum phosphate p-32 may be considered for prior authorization when the most appropriate procedure code is
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C7951
C7952
C9110
C9112
C9192
C91Z2 C9292 C92Z2 C9512
C9592
D45
Tositumomab or Ibritumomab Tiuxetan may be considered for prior authorization when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C8259
C8399
C8499
C84A9
C84Z9
C8519
C8529
C8589
C8599
Chromic phosphate p-32 suspension may be considered for prior authorization when the most appropriate
procedure code is submitted with one of the following ICD-10 diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C782
C786
Strontium-89 chloride may be considered for prior authorization when the most appropriate procedure code is
submitted with one of the following ICD-10 diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C7951
C7952
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.75, “Therapeutic Radiopharmaceuticals,” for additional information.
Transplants – Nonsolid Organ
Prior authorization requests for stem cell transplants must be submitted with the most appropriate diagnosis codes
or combination diagnosis codes as indicated. Texas Medicaid recognizes the following covered indications for stem
cell transplants:
Allogeneic
• Hematological malignancy
ICD-10 Special Bulletin, No. 8
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CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
• Lymphatic malignancy
• Bone marrow disorders
• Hemoglobinopathies
• Platelet function disorders
• Immunodeficiency disorders
• Inherited metabolic disorders
• Multiple myeloma/plasma cell disorders
Autologous
• Hematological malignancy
• Lymphatic malignancy
• Germ cell tumors
• Brain tumors
• Small round blue cell tumors of childhood
• Multiple myeloma/plasma cell disorders
Indications for additional infusions
• Infusion of stem cells for failure to graft (autologous)
• Donor leukocyte infusion for persistent or relapsed malignant disease (allogeneic)
Indications for re-transplantation
• Relapse of disease
• Failure to engraft or poor graft function
Reimbursement for autologous islet cell transplantation is limited to procedure code 48160. Stem cell transplants
for conditions other than those listed will be considered on a case-by-case basis. Documentation for prior authorization must be submitted to determine whether the transplant is medically necessary and appropriate.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and
Physician Assistants Handbook, subsection 9.2.51.7.1, “Allogeneic and Autologous Bone Marrow and Stem
Cell Transplantation;” subsection 9.2.51.7.2, “Autologous Islet Cell Transplantation;” and subsection
9.2.51.7.3, “Prior Authorization for Nonsolid Organ Transplants,” for additional information.
Vaccines and Toxoids
All immunizations must be reported with ICD-10-CM diagnosis code Z23. The type of immunization given will
be identified by the procedure code.
Vaccines and toxoids may be reimbursed for clients who are birth through 20 years of age when they are submitted
with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z00121
Z00129
ICD-10 Special Bulletin, No. 8
65
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 5.3.6, “THSteps
Medical Checkups;” subsection 5.3.11.3, “Immunizations;” subsection 5.4.1, “Separate Identifiable Acute
Care Evaluation and Management Visit;” Appendix B.3.2.2, “Immunizations (Vaccine/Toxoids);” subsection 5.5.1, “Claims Information;” Claims Filing Handbook, subsection 6.3.1, “Diagnosis Coding;” and the
Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.36, “Immunizations for Clients Birth through 20 Years of Age,” for additional information.
Vision Services Nonsurgical
Procedure codes S0620 and S0621 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z0100
Z0101
Prosthetic eyeglasses or contact lenses may be reimbursed when the appropriate procedure code is submitted with
one of the following diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H2701
H2702
H2703
H27111 H27112 H27113 H27121 H27122 H27123 H27131
H27132 H27133 Q123
Z961
Temporary prosthetic eyeglasses or contact lenses after cataract surgery may be reimbursed when the appropriate
procedure code is submitted with the following diagnosis code:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z961
Ultraviolet protection procedure code V2755 may be reimbursed when it is submitted with one of the following
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H2701
H2702
H2703
H27111 H27112 H27113 H27121 H27122 H27123 H27131
H27132 H27133 Q123
Z961
An eye examination with or without refraction (procedure code 92002, 92004, 92012, 92014, or 92015) may be
reimbursed when it is billed with one of the following diagnoses codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A179
A182
A184
A1850
A1851
A1852
A1853
A1854
A1859
A186
A187
A1881
A1884
A1885
A1889
A211
A238
A239
A281
A300
A301
A303
A305
A308
A309
A35
A3982
A400
A401
A403
A409
A4101
A411
A412
A413
A414
A4150
A4151
A4152
A4153
A4159
A4189
A419
A422
A4289
A429
A438
A439
A480
A483
A488
A4901
A492
A493
A498
A5143
A5430
A5431
A5432
A5433
A5439
A711
A719
A740
A800
A801
A802
A8030
A8039
A804
A809
A8100
A8109
A811
A812
A8181
A8189
A819
B0050
B0053
B0059
B0581
B081
B20
B250
B251
B252
B258
B259
B300
B301
B302
B303
B308
B333
B338
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B471
B5801
B5809
B950
B951
B955
B9561
B957
B958
B960
B965
B966
B967
B9681
B9682
B9712
B9730
B9733
B9734
B9735
C6902
C6911
C6912
C6921
C6922
C6942
C6951
C6952
C6961
C6962
C6992
C7940
C7949
D0921
D0922
D3112
D3121
D3122
D3131
D3132
D3152
D3161
D3162
D3191
D3192
E08329
E08331
E08339
E08341
E08349
E0842
E09311
E09319
E09321
E09329
E09349
E09351
E09359
E0936
E0942
E1022
E1029
E10311
E10319
E10321
E10341
E10349
E10351
E10359
E1036
E1042
E1043
E1044
E1049
E1051
E10618
E10620
E10621
E10622
E10628
E10649
E1065
E1069
E108
E109
E1129
E11311
E11319
E11321
E11329
E11349
E11351
E11359
E1136
E1139
E1143
E1144
E1149
E1151
E1152
E11621
E11622
E11628
E11630
E11638
E1169
E118
E119
E1301
E1310
E1329
E13311
E13319
E13321
E13329
E13349
E13351
E13359
E1336
E1339
E1343
E1344
E1349
E1351
E1352
E138
E139
F6089
G35
G360
G43019
G43101
G43109
G43111
G43119
G43419
G43501
G43509
G43511
G43519
G43619
G43701
G43709
G43711
G43719
G43819
G43821
G43829
G43831
G43839
G43A0
G43A1
G43B0
G43B1
G43C0
G500
G510
G511
G512
G514
G932
H00011
H00012
H00014
H00015
H00025
H00031
H00032
H00034
H00035
H0015
H01001
H01002
H01004
H01005
H01015
H01021
H01022
H01024
H01025
H01114
H01115
H01116
H01119
H01121
H01131
H01132
H01134
H01141
H01142
H019
H02001
H02002
H02004
H02005
H02015
H02021
H02022
H02024
H02025
H02035
H02036
H02041
H02042
H02044
H02054
H02055
H02101
H02102
H02104
H02114
H02115
H02121
H02122
H02124
H02134
H02135
H02141
H02142
H02144
ICD-10 Special Bulletin, No. 8
67
B952
B961
B9689
B9739
C6931
C6981
D3101
D3141
E08311
E08351
E09331
E1010
E10329
E1039
E1052
E10630
E1101
E11331
E1140
E1159
E11641
E1311
E13331
E1340
E1359
G43001
G43401
G43601
G43801
G43901
G43C1
G518
H00021
H0011
H01011
H01111
H01122
H01144
H02011
H02031
H02045
H02105
H02125
H02145
B953
B963
B970
B977
C6932
C6982
D3102
D3142
E08319
E08359
E09339
E1011
E10331
E1040
E1059
E10638
E1121
E11339
E1141
E11610
E11649
E1321
E13339
E1341
E13610
G43009
G43409
G43609
G43809
G43909
G43D0
G519
H00022
H0012
H01012
H01112
H01124
H01145
H02012
H02032
H02051
H02111
H02131
H02201
B954
B964
B9711
C6901
C6941
C6991
D3111
D3151
E08321
E0836
E09341
E1021
E10339
E1041
E10610
E10641
E1122
E11341
E1142
E11620
E1165
E1322
E13341
E1342
E13641
G43011
G43411
G43611
G43811
G43919
G43D1
G527
H00024
H0014
H01014
H01113
H01125
H018
H02014
H02034
H02052
H02112
H02132
H02202
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H02204
H02205
H02211
H02212
H02214
H02224
H02225
H02231
H02232
H02234
H0234
H0235
H02401
H02402
H02403
H02431
H02432
H02433
H02511
H02512
H02522
H02524
H02525
H02526
H02531
H0259
H0261
H0262
H0264
H0265
H02714
H02715
H02721
H02722
H02724
H02734
H02735
H0279
H02811
H02812
H02816
H02821
H02822
H02824
H02825
H02835
H02841
H02842
H02844
H02845
H02855
H02861
H02862
H02864
H02865
H02875
H0289
H029
H04001
H04002
H04013
H04021
H04022
H04023
H04031
H04112
H04113
H04121
H04122
H04123
H04141
H04142
H04143
H04151
H04152
H04162
H04163
H0419
H04201
H04202
H04213
H04301
H04302
H04303
H04311
H04332
H04333
H04411
H04412
H04413
H04431
H04432
H04433
H04511
H04512
H04523
H04541
H04542
H04543
H04551
H04561
H04562
H04563
H04571
H04572
H04613
H0469
H04811
H04812
H04813
H05012
H05013
H05021
H05022
H05023
H05041
H05042
H05043
H0510
H05111
H05122
H05123
H0520
H05211
H05212
H05223
H05231
H05232
H05233
H05241
H05252
H05253
H05261
H05262
H05263
H05313
H05321
H05322
H05323
H05331
H05342
H05343
H05351
H05352
H05353
H05411
H05412
H05413
H05421
H05422
H0553
H05811
H05812
H05813
H05821
H059
H10011
H10012
H10013
H10021
H1012
H1013
H10211
H10212
H10213
H10231
H10232
H10233
H1031
H1032
H10403
H10411
H10412
H10413
H10421
H10432
H10433
H1044
H1045
H10501
H10512
H10513
H10521
H10522
H10523
H10811
H10812
H10813
H1089
H109
H11011
H11012
H11013
H11021
H11022
H11033
H11041
H11042
H11043
H11051
H11062
H11063
H1110
H11111
H11112
H11123
H11131
H11132
H11133
H11141
H11152
H11153
H11211
H11212
H11213
H11231
H11232
H11233
H11241
H11242
ICD-10 Special Bulletin, No. 8
68
H02215
H02235
H02421
H02514
H02532
H0270
H02725
H02813
H02831
H02851
H02871
H04003
H04032
H04131
H04153
H04203
H04312
H04421
H04513
H04552
H04573
H0489
H05031
H05112
H05213
H05242
H0530
H05332
H05401
H05423
H05822
H10022
H10221
H1033
H10422
H10502
H10531
H11001
H11023
H11052
H11113
H11142
H11221
H11243
H02221
H0231
H02422
H02515
H02534
H02711
H02731
H02814
H02832
H02852
H02872
H04011
H04033
H04132
H04159
H04211
H04313
H04422
H04521
H04553
H04611
H0500
H05032
H05113
H05221
H05243
H05311
H05333
H05402
H0551
H05823
H10023
H10222
H10401
H10423
H10503
H10532
H11002
H11031
H11053
H11121
H11143
H11222
H1131
H02222
H0232
H02423
H02521
H02535
H02712
H02732
H02815
H02834
H02854
H02874
H04012
H04111
H04133
H04161
H04212
H04331
H04423
H04522
H04559
H04612
H05011
H05033
H05121
H05222
H05251
H05312
H05341
H05403
H0552
H0589
H1011
H10223
H10402
H10431
H10511
H10533
H11003
H11032
H11061
H11122
H11151
H11223
H1132
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H1133
H11411
H11412
H11413
H11421
H11432
H11433
H11441
H11442
H11443
H11821
H11822
H11823
H1189
H119
H15011
H15012
H15013
H15021
H15022
H15033
H15041
H15042
H15043
H15051
H15092
H15093
H15101
H15102
H15103
H15121
H15122
H15123
H15811
H15812
H15823
H15831
H15832
H15833
H15841
H15852
H15853
H1589
H159
H16001
H16012
H16013
H16021
H16022
H16023
H16041
H16042
H16043
H16051
H16052
H16063
H16071
H16072
H16073
H16101
H16112
H16113
H16121
H16122
H16123
H16141
H16142
H16143
H16201
H16202
H16213
H16221
H16222
H16223
H16231
H16242
H16243
H16251
H16252
H16253
H16291
H16292
H16293
H16301
H16302
H16313
H16321
H16322
H16323
H16331
H16392
H16393
H16401
H16402
H16403
H16421
H16422
H16423
H16431
H16432
H16443
H168
H169
H1701
H1702
H1713
H17811
H17812
H17813
H17821
H179
H18001
H18002
H18003
H18011
H18022
H18023
H18031
H18032
H18033
H18051
H18052
H18053
H18061
H18062
H1813
H1820
H18211
H18212
H18213
H18231
H18232
H18233
H1830
H18311
H18322
H18323
H18331
H18332
H18333
H18413
H18421
H18422
H18423
H1843
H18451
H18452
H18453
H18461
H18462
H1851
H1852
H1853
H1854
H1855
H18603
H18611
H18612
H18613
H18621
H18712
H18713
H18721
H18722
H18723
H18739
H18811
H18812
H18813
H18821
H18832
H18833
H18891
H18892
H18893
H20012
H20013
H20021
H20022
H20023
H20041
H20042
H20043
H20051
H20052
H2013
H2021
H2022
H2023
H20811
H20822
H20823
H209
H2101
H2102
H211X3
H21211
H21212
H21213
H21221
H21232
H21233
H21241
H21242
H21243
H21261
H21262
H21263
H21271
H21272
H21302
H21303
H21311
H21312
H21313
H21341
H21342
H21343
H21351
H21352
ICD-10 Special Bulletin, No. 8
69
H11422
H11811
H15001
H15023
H15052
H15111
H15813
H15842
H16002
H16031
H16053
H16102
H16131
H16203
H16232
H16261
H16303
H16332
H16411
H16433
H1703
H17822
H18012
H18041
H18063
H18221
H18312
H1840
H18441
H18463
H1859
H18622
H18731
H18822
H189
H20031
H20053
H20812
H2103
H21222
H21251
H21273
H21321
H21353
H11423
H11812
H15002
H15031
H15053
H15112
H15821
H15843
H16003
H16032
H16061
H16103
H16132
H16211
H16233
H16262
H16311
H16333
H16412
H16441
H1711
H17823
H18013
H18042
H1811
H18222
H18313
H18411
H18442
H1849
H18601
H18623
H18732
H18823
H2000
H20032
H2011
H20813
H211X1
H21223
H21252
H2129
H21322
H2141
H11431
H11813
H15003
H15032
H15091
H15113
H15822
H15851
H16011
H16033
H16062
H16111
H16133
H16212
H16241
H16263
H16312
H16391
H16413
H16442
H1712
H1789
H18021
H18043
H1812
H18223
H18321
H18412
H18443
H1850
H18602
H18711
H18733
H18831
H20011
H20033
H2012
H20821
H211X2
H21231
H21253
H21301
H21323
H2142
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H2143
H21501
H21502
H21503
H21511
H21522
H21523
H21531
H21532
H21533
H21551
H21552
H21553
H21561
H21562
H2189
H219
H22
H25011
H25012
H25033
H25041
H25042
H25043
H25091
H2512
H2513
H2521
H2522
H2523
H2589
H259
H26001
H26002
H26003
H26031
H26032
H26033
H26041
H26042
H26053
H26061
H26062
H26063
H2609
H26111
H26112
H26113
H26121
H26122
H26133
H2620
H26211
H26212
H26213
H26231
H26232
H26233
H2631
H2632
H26412
H26413
H26491
H26492
H26493
H2702
H2703
H27111
H27112
H27113
H27131
H27132
H27133
H278
H279
H30003
H30011
H30012
H30013
H30021
H30032
H30033
H30041
H30042
H30043
H30111
H30112
H30113
H30121
H30122
H30133
H30141
H30142
H30143
H3021
H30812
H30813
H30891
H30892
H30893
H31001
H31002
H31003
H31011
H31012
H31023
H31091
H31092
H31093
H31101
H31112
H31113
H31121
H31122
H31123
H3122
H3123
H3129
H31301
H31302
H31313
H31321
H31322
H31323
H31401
H31412
H31413
H31419
H31421
H31422
H33001
H33002
H33003
H33011
H33012
H33023
H33031
H33032
H33033
H33041
H33052
H33053
H33101
H33102
H33103
H33119
H33191
H33192
H33193
H3321
H33302
H33303
H33311
H33312
H33313
H33331
H33332
H33333
H3341
H3342
H3402
H3403
H3411
H3412
H3413
H34231
H34232
H34233
H34811
H34812
H34823
H34831
H34832
H34833
H349
H35013
H35021
H35022
H35023
H35031
H35042
H35043
H35051
H35052
H35053
H35071
H35072
H35073
H3509
H35101
H35112
H35113
H35121
H35122
H35123
H35141
H35142
H35143
H35151
H35152
H35163
H35171
H35172
H35173
H3521
H3531
H3532
H3533
H35341
H35342
H35353
H35361
H35362
H35363
H35371
H35382
H35383
H3540
H35411
H35412
ICD-10 Special Bulletin, No. 8
70
H21512
H21541
H21563
H25013
H25092
H25811
H26011
H26043
H26101
H26123
H26221
H2633
H268
H27121
H28
H30022
H30101
H30123
H3022
H3091
H31013
H31102
H31129
H31303
H31402
H31423
H33013
H33042
H33111
H3322
H33321
H3343
H34211
H34813
H3500
H35032
H35061
H35102
H35131
H35153
H3522
H35343
H35372
H35413
H21513
H21542
H2181
H25031
H25093
H25812
H26012
H26051
H26102
H26131
H26222
H2640
H269
H27122
H30001
H30023
H30102
H30131
H3023
H3092
H31021
H31103
H3120
H31311
H31403
H318
H33021
H33043
H33112
H3323
H33322
H338
H34212
H34821
H35011
H35033
H35062
H35103
H35132
H35161
H3523
H35351
H35373
H35421
H21521
H21543
H2182
H25032
H2511
H25813
H26013
H26052
H26103
H26132
H26223
H26411
H2701
H27123
H30002
H30031
H30103
H30132
H30811
H3093
H31022
H31111
H3121
H31312
H31411
H319
H33022
H33051
H33113
H33301
H33323
H3401
H34213
H34822
H35012
H35041
H35063
H35111
H35133
H35162
H3530
H35352
H35381
H35422
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H35423
H35431
H35432
H35433
H35441
H35452
H35453
H35461
H35462
H35463
H3553
H3554
H3561
H3562
H3563
H35713
H35721
H35722
H35723
H35731
H3582
H3589
H359
H36
H40001
H40012
H40013
H40021
H40022
H40023
H40041
H40042
H40043
H40051
H40052
H40063
H4010X0
H4010X1
H4010X2
H4010X3
H4011X2
H4011X3
H4011X4
H401210
H401211
H401220
H401221
H401222
H401223
H401224
H401233
H401234
H401310
H401311
H401312
H401321
H401322
H401323
H401324
H401330
H401334
H40141
H40142
H40143
H401510
H401514
H401520
H401521
H401522
H401523
H401532
H401533
H401534
H4020X0
H4020X1
H40211
H40212
H40213
H402210
H402211
H402220
H402221
H402222
H402223
H402224
H402233
H402234
H402290
H40231
H40232
H40243
H4031X0
H4031X1
H4031X2
H4031X3
H4032X2
H4032X3
H4032X4
H4033X0
H4033X1
H4040X4
H4041X0
H4041X1
H4041X2
H4041X3
H4042X2
H4042X3
H4042X4
H4043X0
H4043X1
H4051X0
H4051X1
H4051X2
H4051X3
H4051X4
H4052X3
H4052X4
H4053X0
H4053X1
H4053X2
H4061X1
H4061X2
H4061X3
H4061X4
H4062X0
H4062X4
H4063X0
H4063X1
H4063X2
H4063X3
H40813
H40821
H40822
H40823
H40831
H409
H42
H4301
H4302
H4303
H4321
H4322
H4323
H43311
H43312
H43393
H43811
H43812
H43813
H43821
H439
H44001
H44002
H44003
H44011
H44022
H44023
H44111
H44112
H44113
H44131
H44132
H44133
H4419
H4421
H44311
H44312
H44313
H44319
H44321
H44392
H44393
H4440
H44411
H44412
H44423
H44431
H44432
H44433
H44441
H4450
H44511
H44512
H44513
H44521
H44532
H44533
H44601
H44602
H44603
H44621
H44622
H44623
H44631
H44632
H44643
H44651
H44652
H44653
H44691
H44702
H44703
H44711
H44712
H44713
H44731
H44732
H44733
H44741
H44742
H44753
H44791
H44792
H44793
H44811
H44822
H44823
H4489
H449
H4601
ICD-10 Special Bulletin, No. 8
71
H35442
H3550
H3570
H35732
H40002
H40031
H40053
H4010X4
H401212
H401230
H401313
H401331
H401511
H401524
H4020X2
H402212
H402230
H40233
H4031X4
H4033X2
H4041X4
H4043X2
H4052X0
H4053X3
H4062X1
H4063X4
H40832
H4311
H43313
H43822
H44012
H44121
H4422
H44322
H44413
H44442
H44522
H44611
H44633
H44692
H44721
H44743
H44812
H4602
H35443
H3551
H35711
H35733
H40003
H40032
H40061
H4011X0
H401213
H401231
H401314
H401332
H401512
H401530
H4020X3
H402213
H402231
H40241
H4032X0
H4033X3
H4042X0
H4043X3
H4052X1
H4053X4
H4062X2
H40811
H40833
H4312
H43391
H43823
H44013
H44122
H4423
H44323
H44421
H44443
H44523
H44612
H44641
H44693
H44722
H44751
H44813
H4603
H35451
H3552
H35712
H3581
H40011
H40033
H40062
H4011X1
H401214
H401232
H401320
H401333
H401513
H401531
H4020X4
H402214
H402232
H40242
H4032X1
H4033X4
H4042X1
H4043X4
H4052X2
H4061X0
H4062X3
H40812
H4089
H4313
H43392
H4389
H44021
H44123
H4430
H44391
H44422
H44449
H44531
H44613
H44642
H44701
H44723
H44752
H44821
H4611
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H4612
H4613
H462
H463
H468
H47013
H47021
H47022
H47023
H47031
H47092
H47093
H4710
H4711
H4712
H47143
H4720
H47211
H47212
H47213
H47233
H47291
H47292
H47293
H47311
H47322
H47323
H47331
H47332
H47333
H4741
H4742
H4743
H4749
H47511
H47531
H47532
H47611
H47612
H47621
H47641
H47642
H479
H4901
H4902
H4913
H4921
H4922
H4923
H4931
H4942
H4943
H49889
H499
H5000
H50022
H50031
H50032
H50041
H50042
H5008
H5010
H50111
H50112
H50121
H50141
H50142
H5015
H5016
H5017
H5030
H50311
H50312
H5032
H50331
H50411
H50412
H5042
H5043
H5050
H5054
H5055
H5060
H50611
H50612
H5089
H510
H5111
H5112
H5121
H519
H5201
H5202
H5203
H5211
H52202
H52203
H52211
H52212
H52213
H5231
H5232
H524
H52511
H52512
H52522
H52523
H52531
H52532
H52533
H53002
H53003
H53011
H53012
H53013
H53031
H53032
H53033
H5310
H5311
H53131
H53132
H53133
H53141
H53142
H5316
H5319
H532
H5330
H5331
H5340
H53411
H53412
H53413
H53421
H53432
H53433
H53451
H53452
H53453
H53481
H53482
H53483
H5350
H5351
H5355
H5359
H5360
H5361
H5362
H5372
H538
H539
H543
H5441
H547
H548
H5500
H5501
H5502
H5581
H5589
H5700
H5701
H5702
H57052
H57053
H5711
H5712
H5713
H59022
H59023
H59091
H59092
H59093
K9081
L121
L510
L511
L512
L631
L632
L638
L639
L648
L660
L662
L668
L669
L718
M3219
M328
M329
M3500
M3501
P158
Q100
Q101
Q102
Q103
Q107
Q110
Q111
Q112
Q120
Q124
Q128
Q130
Q131
Q132
Q1381
Q1389
Q140
Q141
Q142
Q158
Q159
Q752
Q840
Q841
ICD-10 Special Bulletin, No. 8
72
H469
H47032
H4713
H4722
H47312
H47391
H47512
H47622
H4903
H4932
H50011
H5005
H50122
H5018
H50332
H5051
H5069
H5122
H5212
H52221
H52513
H526
H53021
H53121
H53143
H5332
H53422
H53461
H5352
H5363
H5442
H5503
H5703
H578
H5988
L513
L651
L719
M3509
Q104
Q121
Q133
Q143
Q842
H47011
H47033
H47141
H47231
H47313
H47392
H47521
H47631
H4911
H4933
H50012
H5006
H50131
H5021
H5034
H5052
H50811
H5123
H5213
H52222
H52519
H527
H53022
H53122
H53149
H5333
H53423
H53462
H5353
H5369
H5461
H5504
H5704
H579
H5989
L518
L652
M320
M60009
Q105
Q122
Q134
Q148
R29891
H47012
H47091
H47142
H47232
H47321
H47393
H47522
H47632
H4912
H4941
H50021
H5007
H50132
H5022
H5040
H5053
H50812
H518
H52201
H52223
H52521
H53001
H53023
H53123
H5315
H5334
H53431
H5347
H5354
H5371
H5462
H5509
H57051
H59021
I10
L519
L658
M3210
P113
Q106
Q123
Q135
Q150
R42
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R483
R51
S0011XA
S0011XD
S0011XS
S00211A
S00211D
S00211S
S00212A
S00212D
S00221S
S00222A
S00222D
S00222S
S00241A
S00242D
S00242S
S00251A
S00251D
S00251S
S00261A
S00261D
S00261S
S00262A
S00262D
S00271S
S00272A
S00272D
S00272S
S01101A
S01102D
S01102S
S01111A
S01111D
S01111S
S01121A
S01121D
S01121S
S01122A
S01122D
S01131D
S01131S
S01132A
S01132D
S01132S
S01142A
S01142D
S01142S
S01151A
S01151D
S01152S
S01159A
S04011A
S04011D
S04011S
S0402XA
S0402XD
S0402XS
S04031A
S04031D
S04032S
S04041A
S04041D
S04041S
S04042A
S0411XD
S0411XS
S0412XA
S0412XD
S0412XS
S0422XA
S0422XD
S0422XS
S0431XA
S0431XD
S0432XS
S0441XA
S0441XD
S0441XS
S0442XA
S0451XD
S0451XS
S0452XA
S0452XD
S0452XS
S0472XS
S04811S
S04812S
S04891S
S04892S
S0502XA
S0502XD
S0502XS
S0511XA
S0511XD
S0512XS
S0521XA
S0521XD
S0521XS
S0522XA
S0531XD
S0531XS
S0532XA
S0532XD
S0532XS
S0541XA
S0541XD
S0541XS
S0542XA
S0542XD
S0551XS
S0552XA
S0552XD
S0552XS
S0561XA
S0562XD
S0562XS
S0571XA
S0571XD
S0571XS
S058X1A
S058X1D
S058X1S
S058X2A
S058X2D
S0591XS
S0592XA
S0592XD
S0592XS
T1501XA
T1502XD
T1502XS
T1511XA
T1511XD
T1511XS
T1581XA
T1581XD
T1581XS
T1582XA
T1582XD
T1591XS
T1592XA
T1592XD
T1592XS
T2000XA
T2009XD
T2009XS
T2010XA
T2010XD
T2010XS
T2020XA
T2020XD
T2020XS
T2029XA
T2029XD
T2030XS
T2039XA
T2039XD
T2039XS
T2059XA
T2601XD
T2601XS
T2602XA
T2602XD
T2602XS
T2612XA
T2612XD
T2612XS
T2621XA
T2621XD
T2622XS
T2631XA
T2631XD
T2631XS
T2632XA
T2641XD
T2641XS
T2642XA
T2642XD
T2642XS
T2652XA
T2652XD
T2652XS
T2661XA
T2661XD
T2662XS
T2671XA
T2671XD
T2671XS
T2672XA
T2691XD
T2691XS
T2692XA
T2692XD
T2692XS
T363X5S
T364X5S
T365X5S
T366X5S
T367X5S
T371X5S
T372X5S
T373X5S
T374X5S
T375X5S
T381X5S
T382X5S
T383X5S
T384X5S
T385X5S
T38815S
T38895S
T38905S
T38995S
T39015S
T39315S
T39395S
T394X5S
T398X5S
T3995XS
ICD-10 Special Bulletin, No. 8
73
S0012XA
S00212S
S00241D
S00252A
S00262S
S01101D
S01112A
S01122S
S01141A
S01151S
S04012A
S04031S
S04042D
S0421XA
S0431XS
S0442XD
S0461XS
S0501XA
S0511XS
S0522XD
S0540XA
S0542XS
S0561XD
S0572XA
S058X2S
T1501XD
T1512XA
T1582XS
T2000XD
T2019XA
T2029XS
T2059XD
T2611XA
T2621XS
T2632XD
T2651XA
T2661XS
T2672XD
T360X5S
T368X5S
T378X5S
T386X5S
T39095S
T400X5S
S0012XD
S00221A
S00241S
S00252D
S00271A
S01101S
S01112D
S01129A
S01141D
S01152A
S04012D
S04032A
S04042S
S0421XD
S0432XA
S0442XS
S0462XS
S0501XD
S0512XA
S0522XS
S0540XD
S0551XA
S0561XS
S0572XD
S0591XA
T1501XS
T1512XD
T1591XA
T2000XS
T2019XD
T2030XA
T2059XS
T2611XD
T2622XA
T2632XS
T2651XD
T2662XA
T2672XS
T361X5S
T3695XS
T3795XS
T387X5S
T391X5S
T401X5S
S0012XS
S00221D
S00242A
S00252S
S00271D
S01102A
S01112S
S01131A
S01141S
S01152D
S04012S
S04032D
S0411XA
S0421XS
S0432XD
S0451XA
S0471XS
S0501XS
S0512XD
S0531XA
S0540XS
S0551XD
S0562XA
S0572XS
S0591XD
T1502XA
T1512XS
T1591XD
T2009XA
T2019XS
T2030XD
T2601XA
T2611XS
T2622XD
T2641XA
T2651XS
T2662XD
T2691XA
T362X5S
T370X5S
T380X5S
T38805S
T392X5S
T402X5S
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T403X5S
T404X5S
T405X5S
T40605S
T40695S
T40995S
T410X5S
T411X5S
T41205S
T41295S
T420X5S
T421X5S
T422X5S
T423X5S
T424X5S
T428X5S
T43015S
T43025S
T431X5S
T43205S
T433X5S
T434X5S
T43505S
T43595S
T43605S
T43695S
T438X5S
T4395XS
T440X5S
T441X5S
T445X5S
T446X5S
T447X5S
T448X5S
T44905S
T452X5S
T453X5S
T454X5S
T45515S
T45525S
T45695S
T457X5S
T458X5S
T4595XS
T460X5S
T464X5S
T465X5S
T466X5S
T467X5S
T468X5S
T471X5S
T472X5S
T473X5S
T474X5S
T475X5S
T4795XS
T480X5S
T481X5S
T48205S
T48295S
T486X5S
T48905S
T48995S
T490X5S
T491X5S
T495X1A
T495X1D
T495X1S
T495X2A
T495X2D
T495X3S
T495X4A
T495X4D
T495X4S
T495X5S
T4995XS
T500X5S
T501X5S
T502X5S
T503X5S
T507X5S
T508X5S
T50905S
T50995S
T50A15S
T50B95S
T50Z15S
T50Z95S
T8131XA
T8131XD
T8132XS
T814XXA
T814XXD T814XXS
T8183XA
T8189XD
T8189XS
T819XXA
T819XXD
T819XXS
T8522XA
T8522XD
T8522XS
T8529XA
T8529XD
T85310S
T85311A
T85311D
T85311S
T85318A
T85320D
T85320S
T85321A
T85321D
T85321S
T85390A
T85390D
T85390S
T85391A
T85391D
T85398S
T8579XA
T8579XD
T8579XS
T8581XA
T8582XD
T8582XS
T8583XA
T8583XD
T8583XS
T8585XA
T8585XD
T8585XS
T8586XA
T8586XD
T8589XS
T886XXS
T887XXS
Z0389
Z09
Z48810
Z5189
Z525
Z7901
Z7902
Z794
Z7951
Z7952
Z79810
Z79811
Z79891
Z79899
Z9001
Z947
Z961
Z9849
Z9883
T407X5S
T413X5S
T425X5S
T43215S
T43615S
T442X5S
T44995S
T45605S
T461X5S
T46905S
T476X5S
T483X5S
T492X5S
T495X2S
T496X5S
T504X5S
T50A25S
T8131XS
T8183XD
T8521XA
T8529XS
T85318D
T85328A
T85391S
T8581XD
T8584XA
T8586XS
Z1289
Z791
Z79818
Z970
T408X5S
T4145XS
T426X5S
T43225S
T43625S
T443X5S
T450X5S
T45615S
T462X5S
T46995S
T477X5S
T484X5S
T493X5S
T495X3A
T497X5S
T505X5S
T50A95S
T8132XA
T8183XS
T8521XD
T85310A
T85318S
T85328D
T85398A
T8581XS
T8584XD
T8589XA
Z4421
Z792
Z7982
Z9841
T40905S
T415X5S
T4275XS
T43295S
T43635S
T444X5S
T451X5S
T45625S
T463X5S
T470X5S
T478X5S
T485X5S
T494X5S
T495X3D
T498X5S
T506X5S
T50B15S
T8132XD
T8189XA
T8521XS
T85310D
T85320A
T85328S
T85398D
T8582XA
T8584XS
T8589XD
Z4422
Z793
Z7983
Z9842
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
B394,
B395,
B399,
E1010,
E1036,
E1039,
H32
H32
H32
E1065
E1065
E1065
E1051,
E1069,
E108,
E118,
E1100,
E1101,
E1065
E1065
E1065
E1165
E1165
E1165
E1139,
E1140,
E1151,
E1169,
E1165
E1165
E1165
E1165
ICD-10 Special Bulletin, No. 8
74
E1040,
E1065
E1121,
E1165
E1021,
E1065
E11311,
E1165
E10311,
E1065
E11319,
E1165
E10319,
E1065
E1136,
E1165
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
Ophthalmological Ultrasound procedure codes 76510, 76511, 76512, 76513, 76516, and 76519 may be reimbursed
when they are billed with one of the following diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A1859
C6941
C6942
C6961
C6962
C7940
C7949
D0921
D0922
D3141
D3142
D3161
D3162
D487
D4981
E08311
E08319
E08321
E08329
E08331
E08339
E08341
E08349
E08351
E08359
E0836
E0839
E0840
E0841
E0842
E0843
E0844
E0849
E0851
E0859
E08610
E08618
E08620
E08621
E08622
E08628
E08630
E08638
E08649
E0865
E0869
E088
E09311
E09319
E09321
E09329
E09331
E09339
E09341
E09349
E09351
E09359
E0936
E0939
E0940
E0941
E0942
E0943
E0944
E0949
E0951
E0959
E09610
E09618
E09620
E09621
E09622
E09628
E09630
E09638
E09649
E0965
E0969
E098
E10311
E10319
E10321
E10329
E10331
E10339
E10341
E10349
E10351
E10359
E1036
E1039
E11311
E11319
E11321
E11329
E11331
E11339
E11341
E11349
E11351
E11359
E1136
E1139
E13311
E13319
E13321
E13329
E13331
E13339
E13341
E13349
E13351
E13359
E1336
E1339
E1340
E1341
E1342
E1343
E1344
E1349
E1359
E13610
E13620
E13621
E13622
E13628
E13638
E13649
E1365
E1369
E138
H02813
H02816
H04151
H04152
H04153
H04159
H0551
H0552
H0553
H1701
H1702
H1703
H1711
H1712
H1713
H17811
H17812
H17813
H17821
H17822
H17823
H1789
H179
H18001
H18002
H18003
H18011
H18012
H18013
H18021
H18022
H18023
H18031
H18032
H18033
H18041
H18042
H18043
H18051
H18052
H18053
H18061
H18062
H18063
H1811
H1812
H1813
H1820
H18211
H18212
H18213
H18221
H18222
H18223
H18231
H18232
H18233
H1830
H18311
H18312
H18313
H18321
H18322
H18323
H18331
H18332
H18333
H1840
H18411
H18412
H18413
H18421
H18422
H18423
H1843
H18441
H18442
H18443
H18451
H18452
H18453
H18461
H18462
H18463
H1849
H1850
H1851
H1852
H1853
H1854
H1855
H1859
H18601
H18602
H18603
H18611
H18612
H18613
H18621
H18622
H18623
H1870
H18711
H18712
H18713
H18721
H18722
H18723
H18731
H18732
H18733
H18739
H18791
H18792
H18793
H18811
H18812
H18813
H18821
H18822
H18823
H18831
H18832
H18833
H18891
H18892
H18893
H189
H2101
H2102
H2103
H2181
H2182
H2189
H22
H25011
H25012
H25013
H25031
H25032
H25033
H25041
H25042
H25043
H25091
H25092
H25093
H2511
H2512
H2513
H2521
H2522
H2523
H25811
H25812
H25813
ICD-10 Special Bulletin, No. 8
75
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H2589
H259
H26001
H26002
H26003
H26031
H26032
H26033
H26041
H26042
H26053
H26061
H26062
H26063
H2609
H26111
H26112
H26113
H26121
H26122
H26133
H2620
H26211
H26212
H26213
H26231
H26232
H26233
H2631
H2632
H26412
H26413
H26491
H26492
H26493
H2702
H2703
H27111
H27112
H27113
H27131
H27132
H27133
H278
H279
H31103
H31111
H31112
H31113
H31121
H3123
H31301
H31302
H31303
H31311
H31322
H31323
H31401
H31402
H31403
H31419
H31421
H31422
H31423
H33001
H33012
H33013
H33021
H33022
H33023
H33041
H33042
H33043
H33051
H33052
H33103
H33111
H33112
H33113
H33119
H3321
H3322
H3323
H33301
H33302
H33313
H33321
H33322
H33323
H33331
H3342
H3343
H338
H3401
H3402
H3413
H34211
H34212
H34213
H34231
H34812
H34813
H34821
H34822
H34823
H349
H3500
H35011
H35012
H35013
H35031
H35032
H35033
H35041
H35042
H35053
H35061
H35062
H35063
H35071
H35101
H35102
H35103
H35111
H35112
H35123
H35131
H35132
H35133
H35141
H35152
H35153
H35161
H35162
H35163
H3521
H3522
H3523
H3530
H3531
H35342
H35343
H35351
H35352
H35353
H35371
H35372
H35373
H35381
H35382
H35412
H35413
H35421
H35422
H35423
H35441
H35442
H35443
H35451
H35452
H35463
H3550
H3551
H3552
H3553
H3563
H3570
H35711
H35712
H35713
H35731
H35732
H35733
H3581
H3582
H4302
H4303
H43811
H43812
H43813
H44611
H44612
H44613
H44621
H44622
H44633
H44641
H44642
H44643
H44651
H44692
H44693
H44701
H44702
H44703
H44721
H44722
H44723
H44731
H44732
H44743
H44751
H44752
H44753
H44791
Q120
Q121
Q122
Q123
Q124
S0551XS
S0552XA
S0552XD
S0552XS
T1501XA
T1502XD
T1502XS
T1511XA
T1511XD
T1511XS
ICD-10 Special Bulletin, No. 8
76
H26011
H26043
H26101
H26123
H26221
H2633
H268
H27121
H28
H31122
H31312
H31411
H33002
H33031
H33053
H33191
H33303
H33332
H3403
H34232
H34831
H35021
H35043
H35072
H35113
H35142
H35171
H3532
H35361
H35383
H35431
H35453
H3554
H35721
H3589
H44601
H44623
H44652
H44711
H44733
H44792
Q128
T1501XD
T1512XA
H26012
H26051
H26102
H26131
H26222
H2640
H269
H27122
H31101
H31123
H31313
H31412
H33003
H33032
H33101
H33192
H33311
H33333
H3411
H34233
H34832
H35022
H35051
H35073
H35121
H35143
H35172
H3533
H35362
H3540
H35432
H35461
H3561
H35722
H36
H44602
H44631
H44653
H44712
H44741
H44793
S0551XA
T1501XS
T1512XD
H26013
H26052
H26103
H26132
H26223
H26411
H2701
H27123
H31102
H31129
H31321
H31413
H33011
H33033
H33102
H33193
H33312
H3341
H3412
H34811
H34833
H35023
H35052
H3509
H35122
H35151
H35173
H35341
H35363
H35411
H35433
H35462
H3562
H35723
H4301
H44603
H44632
H44691
H44713
H44742
H578
S0551XD
T1502XA
T1512XS
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T1581XA
T1581XD
T1581XS
T1582XA
T1582XD
T1591XS
T1592XA
T1592XD
T1592XS
T1582XS
T1591XA
T1591XD
Combination diagnosis codes
Combination Diagnosis Codes (Must be submitted in pairs)
E0821,
E0865
E09319,
E0865
E11311,
E1165
E08311,
E0865
E0936,
E0865
E11319,
E1165
E08319,
E0865
E0940,
E0865
E1136,
E1165
E0836,
E0865
E0951,
E0865
E1139,
E1165
E0840,
E0865
E0969,
E0865
E0851,
E0865
E098,
E0865
E0869,
E0865
E10311,
E1065
E088,
E0865
E10319,
E1065
E0921,
E0865
E1036,
E1065
E09311,
E0865
E1039,
E1065
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
Ophthalmological ultrasound procedure code 76514 may be reimbursed once per lifetime or as medically necessary
dependent on the diagnosis code that is submitted. Procedure code 76514 may be reimbursed once per lifetime when
it is submitted with one of the following diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes): Once per lifetime limitation
H40001
H40002
H40003
H40011
H40012
H40013
H40021
H40022
H40023
H40031
H40032
H40033
H40041
H40042
H40043
H40051
H40052
H40053
H40061
H40062
H40063
H4010X0
H4010X1
H4010X2
H4010X3
H4010X4
H4011X0
H4011X1
H4011X2
H4011X3
H4011X4
H401210
H401211
H401212
H401213
H401214
H401220
H401221
H401222
H401223
H401224
H401230
H401231
H401232
H401233
H401234
H401310
H401311
H401312
H401313
H401314
H401320
H401321
H401322
H401323
H401324
H401330
H401331
H401332
H401333
H401334
H40141
H40142
H40143
H401510
H401511
H401512
H401513
H401514
H401520
H401521
H401522
H401523
H401524
H401530
H401531
H401532
H401533
H401534
H4020X0
H4020X1
H4020X2
H4020X3
H4020X4
H40211
H40212
H40213
H402210
H402211
H402212
H402213
H402214
H402220
H402221
H402222
H402223
H402224
H402230
H402231
H402232
H402233
H402234
H402290
H40231
H40232
H40233
H40241
H40242
H40243
H4031X0
H4031X1
H4031X2
H4031X3
H4031X4
H4032X0
H4032X1
H4032X2
H4032X3
H4032X4
H4033X0
H4033X1
H4033X2
H4033X3
H4033X4
H4041X0
H4041X1
H4041X2
H4041X3
H4041X4
H4042X0
H4042X1
H4042X2
H4042X3
H4042X4
H4043X0
H4043X1
H4043X2
H4043X3
H4043X4
H4051X0
H4051X1
H4051X2
H4051X3
H4051X4
H4052X0
H4052X1
H4052X2
H4052X3
H4052X4
H4053X0
H4053X1
H4053X2
H4053X3
H4053X4
H4061X0
H4061X1
H4061X2
H4061X3
H4061X4
H4062X0
H4062X1
H4062X2
H4062X3
H4062X4
H4063X0
H4063X1
H4063X2
H4063X3
ICD-10 Special Bulletin, No. 8
77
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes): Once per lifetime limitation
H4063X4
H40811
H40812
H40813
H40821
H40822
H40823
H40832
H40833
H4089
H409
H42
H44511
H44512
Q150
H40831
H44513
Ophthalmological ultrasound procedure code 76514 may be reimbursed as medically necessary when it is submitted
with one of the following diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes) One Per Lifetime
H40001
H40002
H40003
H40011
H40012
H40013
H40023
H40031
H40032
H40033
H40041
H40042
H40052
H40053
H40061
H40062
H40063
H4010X0
H4010X3
H4010X4
H4011X0
H4011X1
H4011X2
H4011X3
H401211
H401212
H401213
H401214
H401220
H401221
H401224
H401230
H401231
H401232
H401233
H401234
H401312
H401313
H401314
H401320
H401321
H401322
H401330
H401331
H401332
H401333
H401334
H40141
H401510
H401511
H401512
H401513
H401514
H401520
H401523
H401524
H401530
H401531
H401532
H401533
H4020X1
H4020X2
H4020X3
H4020X4
H40211
H40212
H402211
H402212
H402213
H402214
H402220
H402221
H402224
H402230
H402231
H402232
H402233
H402234
H40232
H40233
H40241
H40242
H40243
H4031X0
H4031X3
H4031X4
H4032X0
H4032X1
H4032X2
H4032X3
H4033X1
H4033X2
H4033X3
H4033X4
H4041X0
H4041X1
H4041X4
H4042X0
H4042X1
H4042X2
H4042X3
H4042X4
H4043X2
H4043X3
H4043X4
H4051X0
H4051X1
H4051X2
H4052X0
H4052X1
H4052X2
H4052X3
H4052X4
H4053X0
H4053X3
H4053X4
H4061X0
H4061X1
H4061X2
H4061X3
H4062X1
H4062X2
H4062X3
H4062X4
H4063X0
H4063X1
H4063X4
H40811
H40812
H40813
H40821
H40822
H40832
H40833
H4089
H409
H42
H44511
Q150
Diagnosis Codes (Submitted as stand-alone diagnosis codes): As medically necessary
A1859
H1701
H1702
H1703
H1711
H1712
H17812
H17813
H17821
H17822
H17823
H1789
H18002
H18003
H18011
H18012
H18013
H18021
H18031
H18032
H18033
H18041
H18042
H18043
H18053
H18061
H18062
H18063
H1811
H1812
H18211
H18212
H18213
H18221
H18222
H18223
H18233
H1830
H18311
H18312
H18313
H18321
H18331
H18332
H18333
H1840
H18411
H18412
ICD-10 Special Bulletin, No. 8
78
H40021
H40043
H4010X1
H4011X4
H401222
H401310
H401323
H40142
H401521
H401534
H40213
H402222
H402290
H4031X1
H4032X4
H4041X2
H4043X0
H4051X3
H4053X1
H4061X4
H4063X2
H40823
H44512
H40022
H40051
H4010X2
H401210
H401223
H401311
H401324
H40143
H401522
H4020X0
H402210
H402223
H40231
H4031X2
H4033X0
H4041X3
H4043X1
H4051X4
H4053X2
H4062X0
H4063X3
H40831
H44513
H1713
H179
H18022
H18051
H1813
H18231
H18322
H18413
H17811
H18001
H18023
H18052
H1820
H18232
H18323
H18421
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes): As medically necessary
H18422
H18423
H1843
H18441
H18442
H18443
H18451
H18453
H18461
H18462
H18463
H1849
H1850
H1851
H1853
H1854
H1855
H1859
H18601
H18602
H18603
H18612
H18613
H18621
H18622
H18623
H1870
H18711
H18713
H18791
H18792
H18793
H18831
H18832
H18833
H21552
H21553
H4040X4
H4041X0
H4041X1
H4041X2
H4041X3
H4042X0
H4042X1
H4042X2
H4042X3
H4042X4
H4043X0
H4043X1
H4043X3
H4043X4
H4720
H47211
H47212
H47213
H4722
H47232
H47233
H47291
H47292
H47293
H5201
H5202
Q133
Q134
Q150
T85310A
T85310D
T85310S
T85311A
T85311S
T85318A
T85318D
T85318S
T85320A
T85320D
T85320S
T85321D
T85321S
T85328A
T85328D
T85328S
T85390A
T85390D
T85391A
T85391D
T85391S
T85398A
T85398D
T85398S
Z48810
H18452
H1852
H18611
H18712
H21551
H4041X4
H4043X2
H47231
H5203
T85311D
T85321A
T85390S
Z947
Corneal topography procedure code 92025 may be reimbursed when it is submitted with one of the following
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H10811
H10812
H10813
H11001
H11002
H11003
H11011
H11012
H11013
H11021
H11022
H11023
H11031
H11032
H11033
H11041
H11042
H11043
H11051
H11052
H11053
H11061
H11062
H11063
H11821
H11822
H11823
H1189
H16001
H16002
H16003
H16011
H16012
H16013
H16021
H16022
H16023
H16031
H16032
H16033
H16041
H16042
H16043
H16051
H16052
H16053
H16061
H16062
H16063
H16071
H16072
H16073
H1701
H1702
H1703
H1711
H1712
H1713
H17811
H17812
H17813
H17821
H17822
H17823
H1789
H179
H1811
H1812
H1813
H1820
H18221
H18222
H18223
H18231
H18232
H18233
H1840
H18411
H18412
H18413
H18451
H18452
H18453
H18461
H18462
H18463
H1849
H18601
H18602
H18603
H18611
H18612
H18613
H18621
H18622
H18623
H1870
H18711
H18712
H18713
H18721
H18722
H18723
H18731
H18732
H18733
H18739
H18791
H18792
H18793
H18831
H18832
H18833
S0521XA
S0521XD
S0521XS
S0522XA
S0522XD
S0522XS
S0531XA
S0531XD
S0531XS
S0532XA
S0532XD
S0532XS
T2611XA
T2611XD
T2611XS
T2612XA
T2612XD
T2612XS
T2661XA
T2661XD
T2661XS
T2662XA
T2662XD
T2662XS
T85310A
T85310D
T85310S
T85311A
T85311D
T85311S
T85318A
T85318D
T85318S
T85320A
T85320D
T85320S
T85321A
T85321D
T85321S
T85328A
T85328D
T85328S
T85390A
T85390D
T85390S
T85391A
T85391D
T85391S
T85398A
T85398D
T85398S
Z48810
Z947
Z9841
Z9842
Z9849
Z9883
Polcycarbonate lens procedure code V2784 may be reimbursed when it is submitted with one of the following
diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F840
F843
F845
F848
F849
F951
G20
G2111
ICD-10 Special Bulletin, No. 8
79
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G2119
G213
G214
G218
G3183
G40009
G40019
G40101
G40109
G40111
G40211
G40219
G40301
G40309
G40311
G40419
G40501
G40509
G40801
G40802
G4089
G40901
G40909
G40911
G40919
G40A19
G40B01
G40B09
G40B11
G40B19
G7113
G7114
G7119
G712
G713
G723
G7241
G7249
G7281
G7289
G801
G802
G804
G808
G809
H33011
H33012
H33013
H33021
H33022
H33033
H33041
H33042
H33043
H33051
H33192
H33193
H3321
H3322
H3323
H33311
H33312
H33313
H33321
H33322
H33333
H3341
H3342
H3343
H338
H53011
H53012
H53013
H53021
H53022
H53033
H5441
H5442
H5451
H5452
H8109
H8110
H8111
H8112
H8113
H8123
H81311
H81312
H81313
H81319
H81399
H8301
H8302
H8303
H8309
H8319
H832X1
H832X2
H832X3
H832X9
P108
P524
P526
P528
Q8740
Q8743
Q900
Q901
Q902
Q909
S06891A
S06891D
S06891S
S06892A
S06892D
S06893S
S06894A
S06894D
S06894S
S06895A
S06896D
S06896S
S06899A
S06899D
S06899S
S069X1A
S069X1D
S069X1S
S069X2A
S069X2D
S069X3S
S069X4A
S069X4D
S069X4S
S069X5A
S069X6D
S069X6S
S069X9A
S069X9D
S069X9S
T8522XA
T8522XD
T8522XS
T8529XA
T8529XD
T85310S
T85311A
T85311D
T85311S
T85318A
T85320D
T85320S
T85321A
T85321D
T85321S
T85390A
T85390D
T85390S
T85391A
T85391D
T85398S
T8579XA
T8579XD
T8579XS
G3184
G40119
G40401
G40803
G40A01
G710
G718
G729
H33001
H33023
H33052
H33301
H33323
H53001
H53023
H8101
H8120
H81391
H8311
P100
Q87410
S06890A
S06892S
S06895D
S069X0A
S069X2S
S069X5D
T8521XA
T8529XS
T85318D
T85328A
T85391S
G35
G40201
G40409
G40804
G40A09
G7111
G720
G737
H33002
H33031
H33053
H33302
H33331
H53002
H53031
H8102
H8121
H81392
H8312
P101
Q87418
S06890D
S06893A
S06895S
S069X0D
S069X3A
S069X5S
T8521XD
T85310A
T85318S
T85328D
T85398A
G40001
G40209
G40411
G40813
G40A11
G7112
G722
G800
H33003
H33032
H33191
H33303
H33332
H53003
H53032
H8103
H8122
H81393
H8313
P104
Q8742
S06890S
S06893D
S06896A
S069X0S
S069X3D
S069X6A
T8521XS
T85310D
T85320A
T85328S
T85398D
S06895A,
S0190XA
S06896A,
S0190XA
S06899A,
S0190XA
Combination diagnosis codes
Combination Diagnosis Codes (Must be submitted in pairs)
S06890A,
S06891A,
S06892A,
S06893A,
S06894A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
ICD-10 Special Bulletin, No. 8
80
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Sensorimotor examination procedure code 92060 and orthoptic and pleoptic training procedure code 92065 may
be reimbursed when they are submitted with one of the following diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H50011
H50012
H50021
H50022
H50031
H50032
H50041
H50042
H5005
H5006
H5007
H5008
H50111
H50112
H50121
H50122
H50131
H50132
H50141
H50142
H5015
H5016
H5017
H5018
H5021
H5022
H50311
H50312
H5032
H50331
H50332
H5034
H50411
H50412
H5042
H5043
H5051
H5052
H5053
H5054
H5055
H50611
H50612
H5069
H50811
H50812
H5089
H5111
H5112
H518
H53011
H53012
H53013
H53021
H53022
H53023
H53031
H53032
H53033
H5501
H5502
H5503
H5504
H5509
H5581
H5589
Eye photography procedure codes 92285, 92286, and 92287 may be reimbursed when they are submitted with one
of the following diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A000
A001
A009
A179
A1803
A182
A1853
A1854
A1859
A186
A187
A1881
A230
A231
A232
A233
A238
A239
A303
A305
A308
A309
A35
A3686
A409
A4101
A411
A412
A413
A414
A4159
A4189
A419
A420
A421
A422
A438
A439
A480
A483
A488
A4901
A719
A740
A800
A801
A802
A8030
A812
A8181
A8189
A819
B0050
B0053
B0821
B0822
B083
B09
B1001
B1009
B251
B252
B258
B259
B300
B301
B333
B334
B338
B471
B479
B950
B955
B9561
B957
B958
B960
B961
B967
B9681
B9682
B9689
B970
B9711
B9735
B9739
B977
E1010
E1011
E1021
E10321
E10329
E10331
E10339
E10341
E10349
E1040
E1041
E1042
E1043
E1044
E1049
E10618
E10620
E10621
E10622
E10628
E10630
E1069
E108
E109
E1101
E1121
E1122
E11329
E11331
E11339
E11341
E11349
E11351
E1141
E1142
E1143
E1144
E1149
E1151
E11621
E11622
E11628
E11630
E11638
E11641
E119
E1301
E1310
E1311
E1321
E1322
E13329
E13331
E13339
E13341
E13349
E13351
E1341
E1342
E1343
E1344
E1349
E1351
E138
E139
F0150
F0151
F0280
F0281
F061
F062
F0630
F0631
F0632
F0633
F0781
F09
F1010
F10120
F10121
F10129
ICD-10 Special Bulletin, No. 8
81
A184
A1884
A240
A3982
A4150
A4289
A492
A8039
B0059
B1081
B302
B951
B963
B9712
E1022
E10351
E1051
E10638
E1129
E11359
E1152
E11649
E1329
E13359
E1352
F0390
F0634
F1014
A1850
A1885
A281
A400
A4151
A429
A493
A804
B0581
B1082
B303
B952
B964
B9730
E1029
E10359
E1052
E10641
E11311
E1136
E1159
E1165
E13311
E1336
E1359
F04
F064
F10150
A1851
A1889
A300
A401
A4152
A430
A498
A809
B081
B20
B308
B953
B965
B9733
E10311
E1036
E1059
E10649
E11319
E1139
E11610
E1169
E13319
E1339
E13610
F05
F068
F10151
A1852
A211
A301
A403
A4153
A431
A711
A811
B0820
B250
B309
B954
B966
B9734
E10319
E1039
E10610
E1065
E11321
E1140
E11620
E118
E13321
E1340
E13641
F060
F070
F10159
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F10180
F10181
F10182
F10188
F1019
F1020
F10230
F10231
F10239
F1024
F10250
F10251
F10281
F10282
F10288
F1029
F10921
F10929
F1097
F10980
F10982
F1099
F1110
F11121
F11181
F11182
F11188
F1119
F1120
F1121
F11250
F11251
F11259
F11281
F11282
F11288
F1194
F11950
F11951
F11959
F11981
F11982
F12122
F12150
F12151
F12159
F12180
F12188
F12222
F12250
F12251
F12259
F12280
F12288
F12950
F12951
F12959
F12980
F12988
F1299
F13159
F13180
F13181
F13182
F13188
F1320
F13250
F13251
F13259
F1326
F1327
F13280
F13951
F13959
F1396
F1397
F13980
F13981
F14122
F1414
F14150
F14151
F14159
F14180
F1420
F1421
F14221
F14222
F1423
F1424
F14281
F14282
F14288
F1429
F14921
F14922
F14980
F14981
F14982
F14988
F1499
F1510
F15151
F15159
F15180
F15181
F15182
F15188
F15222
F1523
F1524
F15250
F15251
F15259
F1529
F15920
F15921
F15922
F1593
F1594
F15981
F15982
F15988
F1599
F1610
F16121
F16159
F16180
F16183
F16188
F1619
F1620
F16251
F16259
F16280
F16283
F16288
F1629
F16959
F16980
F16983
F16988
F1699
F17200
F17210
F17218
F17220
F17228
F17290
F17298
F18151
F18159
F1817
F18180
F18188
F1819
F18250
F18251
F18259
F1827
F18280
F18288
F18951
F18959
F1897
F18980
F18988
F1899
F19150
F19151
F19159
F1916
F1917
F19180
F1920
F1921
F19221
F19222
F19230
F19232
F19259
F1926
F1927
F19280
F19281
F19282
F19930
F19932
F19939
F1994
F19950
F19951
F19981
F19982
F19988
F1999
F200
F201
F209
F21
F22
F23
F24
F250
F29
F3010
F3011
F3012
F3013
F302
F3110
F3111
F3112
F3113
F312
F3130
F3160
F3161
F3162
F3163
F3164
F3170
F3175
F3176
F3177
F3178
F3181
F3189
F323
F324
F325
F328
F329
F330
F3341
F3342
F338
F339
F340
F341
F4001
F4002
F4010
F4011
F40210
F40218
F40232
F40233
F40240
F40241
F40242
F40243
F408
F409
F410
F411
F413
F418
F4311
F4312
F4320
F4321
F4322
F4323
ICD-10 Special Bulletin, No. 8
82
F1021
F10259
F10950
F1114
F11221
F1129
F11988
F1219
F1229
F1310
F1321
F13281
F13982
F14181
F14250
F1494
F15121
F1519
F15280
F15950
F16122
F1621
F16921
F17201
F1810
F1820
F1829
F1910
F19181
F19239
F19288
F19959
F202
F251
F303
F3131
F3171
F319
F331
F348
F40220
F40248
F419
F4324
F10220
F1026
F10951
F11150
F11222
F11921
F1199
F1220
F1290
F13120
F13230
F13282
F13988
F14182
F14251
F14950
F15122
F1520
F15281
F15951
F1614
F16221
F1694
F17203
F18121
F1821
F18921
F19121
F19182
F1924
F1929
F1996
F205
F258
F304
F3132
F3172
F320
F332
F349
F40228
F40290
F42
F4325
F10221
F1027
F10959
F11151
F1123
F11922
F1210
F1221
F12921
F13150
F13232
F13288
F1410
F14188
F14259
F14951
F1514
F1521
F15282
F15959
F16150
F1624
F16950
F17208
F1814
F18221
F1894
F19122
F19188
F19250
F19921
F1997
F2081
F259
F308
F314
F3173
F321
F333
F39
F40230
F40291
F430
F4329
F10229
F10280
F1096
F11159
F1124
F1193
F12121
F12221
F12922
F13151
F13239
F13950
F14121
F1419
F14280
F14959
F15150
F15221
F15288
F15980
F16151
F16250
F16951
F17209
F18150
F1824
F18950
F1914
F1919
F19251
F19922
F19980
F2089
F28
F310
F315
F3174
F322
F3340
F4000
F40231
F40298
F4310
F438
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Medicaid Fee-For-Service and Managed Care Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F440
F441
F444
F446
F447
F4481
F4520
F4521
F4522
F4529
F4541
F4542
F489
F5000
F5001
F5002
F502
F508
F5104
F5109
F5111
F5112
F5119
F513
F520
F521
F5221
F5222
F5231
F5232
F529
F53
F551
F553
F59
F600
F605
F606
F607
F6081
F6089
F609
F6381
F6389
F639
F641
F642
F648
F654
F6551
F6552
F6581
F6589
F659
F6813
F688
F800
F801
F802
F804
F8181
F8189
F819
F82
F840
F843
F89
F900
F901
F902
F908
F909
F919
F930
F938
F939
F940
F941
F952
F958
F959
F980
F981
F9821
F988
F989
F99
G44209 H9325
K9081
R451
R457
R480
Z87890
F4489
F458
F509
F514
F524
F601
F630
F650
F66
F8089
F845
F911
F942
F9829
L081
F449
F459
F5101
F515
F525
F602
F631
F651
F6810
F809
F848
F912
F948
F983
L444
F450
F481
F5102
F518
F526
F603
F632
F652
F6811
F810
F849
F913
F950
F984
M60009
F451
F488
F5103
F519
F528
F604
F633
F653
F6812
F812
F88
F918
F951
F985
R37
E1039,
E1065
E1136,
E1165
E1040,
E1065
E1139,
E1165
E1051,
E1065
E1140,
E1165
E1069,
E1065
E1151,
E1165
Combination diagnosis codes
Combination Diagnosis Codes (Must be submitted in pairs)
E1010,
E1011,
E1021,
E10311,
E10319,
E1036,
E1065
E1065
E1065
E1065
E1065
E1065
E108,
E1100,
E1101,
E1121,
E11311,
E11319,
E1065
E1165
E1165
E1165
E1165
E1165
E1169,
E118,
F0390,
E1165
E1165
F05
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual Radiology and Laboratory Services Handbook,
subsection 3.2.7.8, “Nonsurgical Vision Services,” for additional information.
Vitamin B12 (Cyanocobalamin) Injections
Vitamin B12 procedure code J3420 may be reimbursed when submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B700
D510
D511
D512
D513
D518
D520
D521
D528
D529
D531
D649
E538
E710
E71110
E71111
E71118
E71120
E71121
E71128
E7119
E712
E7210
E7211
E7212
E7219
E723
E7251
E7259
E728
G621
G63
H4611
H4612
H4613
H463
K5660
K900
K901
K902
K903
K9089
K909
K911
K912
Z903
Z9221
Z980
ICD-10 Special Bulletin, No. 8
83
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
For the list of diagnoses in the table above, documentation in the medical records must include rationale as to why
the client was unable to be treated with oral therapy.
Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician
Assistants Handbook, subsection 9.2.39.25, “Vitamin B12 (Cyanocobalamin) Injections,” for additional
information.
BEHAVIORAL HEALTH SERVICES
ICD-10 and DSM Diagnosis Codes for Behavioral Health Services
Inpatient Behavioral Health
Psychotherapy procedure code 90832, 90833, 90834, 90836, 90837, 90838, 90847, 90853, or 90899 for Alzheimer’s disease or dementia may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
G3184
R41841
Psychological Testing and Neuropsychological Testing
Psychological testing (procedure code 96101) and neuropsychological testing (procedure code 96118) may be
reimbursed when they are submitted by a psychiatrist, psychologist, licensed psychological associate (LPA), or a
provisionally licensed psychologist (PLP) with one of the following ICD-10-CM diagnosis codes or combination
diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A8100
A8101
A8109
A8181
A8183
D8681
E7500
E7501
E7502
E7509
E7523
E7525
E7529
E754
F0390
F060
F061
F062
F0630
F0631
F064
F068
F070
F0781
F09
F10129
F1014
F10150
F10151
F10159
F10188
F1019
F1020
F1021
F10220
F10231
F10232
F10239
F1024
F10250
F10280
F10281
F10282
F10288
F1029
F1094
F10950
F10951
F10959
F1096
F10988
F1099
F1110
F11120
F11121
F11159
F11181
F11182
F11188
F1119
F11221
F11222
F11229
F1123
F1124
F11281
F11282
F11288
F1129
F11920
F1193
F1194
F11950
F11951
F11959
F1199
F1210
F12120
F12121
F12122
F12159
F12180
F12188
F1219
F1220
B1001
E7510
F0391
F0632
F1010
F10180
F10221
F10251
F10920
F10980
F1114
F1120
F11250
F11921
F11981
F12129
F1221
B1009
E7511
F04
F0633
F10120
F10181
F10229
F10259
F10921
F10981
F11150
F1121
F11251
F11922
F11982
F12150
F12220
B451
E7519
F05
F0634
F10121
F10182
F10230
F1026
F10929
F10982
F11151
F11220
F11259
F11929
F11988
F12151
F12221
* These diagnosis codes are only payable to procedure code 96118
ICD-10 Special Bulletin, No. 8
84
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F12222
F12229
F12250
F12251
F12259
F12920
F12921
F12922
F12929
F12950
F12988
F1299
F1310
F13120
F13121
F13151
F13159
F13180
F13181
F13182
F13220
F13221
F13229
F13230
F13231
F13250
F13251
F13259
F1326
F13280
F13920
F13921
F13929
F13930
F13931
F13950
F13951
F13959
F1396
F13980
F1399
F1410
F14120
F14121
F14122
F14151
F14159
F14180
F14181
F14182
F1421
F14220
F14221
F14222
F14229
F14251
F14259
F14280
F14281
F14282
F14921
F14922
F14929
F1494
F14950
F14981
F14982
F14988
F1499
F1510
F15129
F1514
F15150
F15151
F15159
F15188
F1519
F1520
F1521
F15220
F1523
F1524
F15250
F15251
F15259
F15288
F1529
F15920
F15921
F15922
F15950
F15951
F15959
F15980
F15981
F1610
F16120
F16121
F16122
F16129
F16159
F16180
F16183
F16188
F1619
F16229
F1624
F16250
F16251
F16259
F1629
F16920
F16921
F16929
F1694
F16980
F16983
F16988
F1699
F17208
F17228
F17229
F17298
F17299
F1810
F1814
F18150
F18151
F18159
F18180
F1821
F18220
F18221
F18229
F1824
F18280
F18288
F1829
F1890
F18920
F18950
F18951
F18959
F18980
F18988
F19121
F19122
F19129
F1914
F19150
F19180
F19181
F19182
F19188
F1919
F19221
F19222
F19229
F19230
F19231
F19250
F19251
F19259
F1926
F19280
F1929
F19920
F19921
F19922
F19929
F19939
F1994
F19950
F19951
F19959
F19982
F19988
F1999
F200
F201
F2081
F2089
F209
F21
F22
F251
F258
F259
F28
F29
F12280
F12951
F13129
F13188
F13232
F13281
F13932
F13981
F14129
F14188
F1423
F14288
F14951
F15120
F15180
F15221
F15280
F15929
F15982
F1614
F1620
F16280
F16950
F17209
F18120
F18188
F18250
F18921
F1899
F19151
F1920
F19232
F19281
F19930
F1996
F202
F23
F3010
F12288
F12959
F1314
F1320
F13239
F13282
F13939
F13982
F1414
F1419
F1424
F1429
F14959
F15121
F15181
F15222
F15281
F1593
F15988
F16150
F16220
F16283
F16951
F17218
F18121
F1819
F18251
F18929
F1910
F19159
F1921
F19239
F19282
F19931
F19980
F203
F24
F3011
F1229
F12980
F13150
F1321
F1324
F13288
F1394
F13988
F14150
F1420
F14250
F14920
F14980
F15122
F15182
F15229
F15282
F1594
F1599
F16151
F16221
F16288
F16959
F17219
F18129
F1820
F18259
F1894
F19120
F1916
F19220
F1924
F19288
F19932
F19981
F205
F250
F3012
* These diagnosis codes are only payable to procedure code 96118
ICD-10 Special Bulletin, No. 8
85
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F3013
F302
F303
F304
F308
F3111
F3112
F3113
F312
F3130
F315
F3160
F3161
F3162
F3163
F3175
F3176
F3177
F3178
F3181
F322
F323
F324
F325
F328
F332
F333
F3341
F3342
F339
F39
F4001
F4002
F4010
F4011
F40228
F40230
F40231
F40232
F40233
F40243
F40248
F40290
F40291
F40298
F411
F413
F418
F419
F42
F4312
F4320
F4321
F4322
F4323
F438
F439
F440
F441
F444
F4481
F4489
F449
F450
F451
F4529
F4541
F4542
F458
F459
F489
F5000
F5001
F5002
F502
F5102
F5103
F5104
F5105
F5109
F5119
F513
F514
F515
F518
F5221
F5222
F5231
F5232
F524
F54
F551
F553
F600
F601
F605
F606
F607
F6081
F6089
F632
F633
F6381
F6389
F639
F649
F650
F651
F652
F653
F6581
F6589
F659
F66
F6810
F69
F70
F71
F72
F73
F802
F804
F8089
F809
F8181
F842
F843
F845
F849
F88
F908
F909
F911
F912
F913
F938
F939
F940
F941
F948
F959
F980
F981
F9821
F9829
G000
G001
G002
G003
G008
G030
G031
G038
G039
G0400
G0430
G0431
G0439
G0481
G0489
G054
G060
G061
G062
G07
G3182
G3184
G319
G3289
G35
G40019
G40101
G40109
G40111
G40119
G40219
G40301
G40309
G40311
G40319
G40804
G40811
G40813
G40821
G40822
G40901
G40909
G40911
G40919
G40A01
F309
F3131
F3164
F319
F329
F340
F40210
F40240
F408
F430
F4324
F445
F4520
F481
F508
F5111
F519
F525
F602
F609
F641
F654
F6811
F79
F819
F900
F918
F950
F983
G009
G0401
G0490
G210
G40001
G40201
G40801
G40823
G40A09
F310
F3132
F3173
F320
F330
F341
F40218
F40241
F409
F4310
F4325
F446
F4521
F482
F509
F5112
F520
F526
F603
F630
F642
F6551
F6812
F800
F82
F901
F919
F951
F984
G01
G0402
G0491
G3101
G40009
G40209
G40802
G40824
G40A11
F3110
F314
F3174
F321
F331
F348
F40220
F40242
F410
F4311
F4329
F447
F4522
F488
F5101
F5113
F521
F529
F604
F631
F648
F6552
F6813
F801
F840
F902
F930
F952
F989
G02
G042
G053
G3181
G40011
G40211
G40803
G4089
G40A19
* These diagnosis codes are only payable to procedure code 96118
ICD-10 Special Bulletin, No. 8
86
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G44209
G450
G451
G454
G458
G4721
G4722
G4723
G4724
G4725
G910
G911
G912
G92
G930
G9349
G937
G9381
G9389
G939
H93293
I6001
I6002
I6011
I6012
I6032
I604
I6051
I6052
I606
I613
I614
I615
I616
I618
I6203
I621
I6300
I63011
I63012
I6309
I6310
I63111
I63112
I6312
I6320
I63211
I63212
I63231
I63232
I63321
I63322
I63331
I63332
I63341
I63412
I63421
I63422
I63431
I63432
I6350
I63511
I63512
I63519
I63521
I63532
I63539
I63541
I63542
I63549
I6503
I651
I6521
I6522
I6523
I6602
I6603
I6611
I6612
I6613
I663
I668
I669
I671
I672
I677
I6781
I6782
I6789
I679
I6901
I69020
I69021
I69022
I69023
I69033
I69034
I69041
I69042
I69043
I69053
I69054
I69061
I69062
I69063
I69091
I69092
I69093
I69098
I6911
I69123
I69128
I69131
I69132
I69133
I69143
I69144
I69151
I69152
I69153
I69163
I69164
I69165
I69190
I69191
I6921
I69220
I69221
I69222
I69223
I69233
I69234
I69241
I69242
I69243
I69253
I69254
I69261
I69262
I69263
I69291
I69292
I69293
I69298
I6931
I69323
I69328
I69331
I69332
I69333
I69343
I69344
I69351
I69352
I69353
I69363
I69364
I69365
I69390
I69391
I6981
I69820
I69821
I69822
I69823
I69833
I69834
I69841
I69842
I69843
I69853
I69854
I69861
I69862
I69863
I69891
I69892
I69893
I69898
I69951
I69961
I69962
I69963
I69964
I69965
P521
P5221
P5222
P523
P525
G459
G4726
G931
G94
I6021
I608
I6200
I6302
I63131
I6329
I63342
I63441
I63522
I6359
I658
I6621
I674
I680
I69028
I69044
I69064
I69120
I69134
I69154
I69192
I69228
I69244
I69264
I69320
I69334
I69354
I69392
I69828
I69844
I69864
I69952
P102
P84
G468
G4727
G9340
H93291
I6022
I610
I6201
I63031
I63132
I63311
I6339
I63442
I63529
I6501
I659
I6622
I675
I682
I69031
I69051
I69065
I69121
I69141
I69161
I69193
I69231
I69251
I69265
I69321
I69341
I69361
I69393
I69831
I69851
I69865
I69953
P103
P90
G4720
G4729
G9341
H93292
I6031
I611
I6202
I63032
I6319
I63312
I63411
I6349
I63531
I6502
I6601
I6623
I676
I688
I69032
I69052
I69090
I69122
I69142
I69162
I69198
I69232
I69252
I69290
I69322
I69342
I69362
I69398
I69832
I69852
I69890
I69954
P520
R0901
* These diagnosis codes are only payable to procedure code 96118
ICD-10 Special Bulletin, No. 8
87
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R0902
R413
R41840
R41841
R41842
R450
R453
R454
R457
R45850
R4589
R5600
R5601
R569
S060X0A
S060X1D
S060X1S
S060X2A
S060X2D
S060X2S
S060X4A
S060X4D
S060X4S
S060X5A
S060X5D
S060X6S
S060X9A
S060X9D
S060X9S
S06306D
S06310S
S06311A
S06311D
S06311S
S06312A
S06313D
S06313S
S06314A
S06314D
S06314S
S06316A
S06316D
S06316S
S06319A
S06319D
S06320S
S06321A
S06321D
S06321S
S06322A
S06323D
S06323S
S06324A
S06324D
S06324S
S06326A
S06326D
S06326S
S06329A
S06329D
S06330S
S06331A
S06331D
S06331S
S06332A
S06333D
S06333S
S06334A
S06334D
S06334S
S06336A
S06336D
S06336S
S06339A
S06339D
S06340S
S06341A
S06341D
S06341S
S06342A
S06343D
S06343S
S06344A
S06344D
S06344S
S06346A
S06346D
S06346S
S06349A
S06349D
S06351A
S06351D
S06351S
S06352A
S06352D
S06353S
S06354A
S06354D
S06354S
S06355A
S06356D
S06356S
S06359A
S06359D
S06359S
S06361A
S06361D
S06361S
S06362A
S06362D
S06363S
S06364A
S06364D
S06364S
S06365A
S06366D
S06366S
S06369A
S06369D
S06369S
S06371A
S06371D
S06371S
S06372A
S06372D
S06373S
S06374A
S06374D
S06374S
S06375A
S06376D
S06376S
S06379A
S06379D
S06379S
S06381A
S06381D
S06381S
S06382A
S06382D
S06383S
S06384A
S06384D
S06384S
S06385A
S06386S
S06389A
S06389D
S06389S
S064X0A
S064X1D
S064X1S
S064X2A
S064X2D
S064X2S
S064X4A
S064X4D
S064X4S
S064X5A
S064X5D
S064X6S
S064X9A
S064X9D
S064X9S
S065X0A
S065X1D
S065X1S
S065X2A
S065X2D
S065X2S
S065X4A
S065X4D
S065X4S
S065X5A
S065X5D
S065X6S
S065X9A
S065X9D
S065X9S
S066X0A
S066X1D
S066X1S
S066X2A
S066X2D
S066X2S
S066X4A
S066X4D
S066X4S
S066X5A
S066X5D
R41843
R45851
S060X0D
S060X3A
S060X5S
S06306S
S06312D
S06315A
S06319S
S06322D
S06325A
S06329S
S06332D
S06335A
S06339S
S06342D
S06345A
S06349S
S06352S
S06355D
S06360A
S06362S
S06365D
S06370A
S06372S
S06375D
S06380A
S06382S
S06385D
S064X0D
S064X3A
S064X5S
S065X0D
S065X3A
S065X5S
S066X0D
S066X3A
S066X5S
R41844
R4586
S060X0S
S060X3D
S060X6A
S06310A
S06312S
S06315D
S06320A
S06322S
S06325D
S06330A
S06332S
S06335D
S06340A
S06342S
S06345D
S06350A
S06353A
S06355S
S06360D
S06363A
S06365S
S06370D
S06373A
S06375S
S06380D
S06383A
S06385S
S064X0S
S064X3D
S064X6A
S065X0S
S065X3D
S065X6A
S066X0S
S066X3D
S066X6A
R4189
R4587
S060X1A
S060X3S
S060X6D
S06310D
S06313A
S06315S
S06320D
S06323A
S06325S
S06330D
S06333A
S06335S
S06340D
S06343A
S06345S
S06350S
S06353D
S06356A
S06360S
S06363D
S06366A
S06370S
S06373D
S06376A
S06380S
S06383D
S06386A
S064X1A
S064X3S
S064X6D
S065X1A
S065X3S
S065X6D
S066X1A
S066X3S
S066X6D
* These diagnosis codes are only payable to procedure code 96118
ICD-10 Special Bulletin, No. 8
88
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S066X6S
S066X9A
S066X9D
S066X9S
S06890A
S06891D
S06891S
S06892A
S06892D
S06892S
S06894A
S06894D
S06894S
S06895A
S06895D
S06896S
S06897S
S06899A
S06899D
S06899S
S069X1A
S069X1D
S069X1S
S069X2A
S069X2D
S069X3S
S069X4A
S069X4D
S069X4S
S069X5A
S069X6D
S069X6S
S069X9A
S069X9D
S069X9S
T5802XA
T5802XD
T5803XA
T5803XD
T5804XA
T5811XD
T5811XS
T5812XA
T5812XD
T5813XA
T5814XS
T582X1A
T582X1D
T582X1S
T582X2A
T582X4A
T582X4D
T588X1A
T588X1D
T588X1S
T588X3D
T588X3S
T588X4A
T588X4D
T588X4S
T5892XA
T5892XD
T5893XA
T5893XD
T5894XA
T71111S
T71112A
T71112S
T71113A
T71113D
T71114S
T71121A
T71121D
T71121S
T71122A
T71123S
T71124A
T71124S
T71131A
T71131D
T71133D
T71133S
T71134A
T71134D
T71134S
T71143A
T71143D
T71143S
T71144A
T71144D
T71151S
T71152A
T71152D
T71152S
T71153A
T71154D
T71154S
T71161A
T71162A
T71163A
T71193A
T71194A
T71194D
T71194S
T7120XA
T71223A
T71224A
T71231A
T71232A
T71233A
T7402XA
T7402XD
T7402XS
T7411XA
T7411XD
T7412XS
T7421XA
T7421XD
T7421XS
T7422XA
T751XXD T751XXS
T7602XA
T7602XD
T7602XS
T7612XA
T7612XD
T7612XS
T7621XA
T7621XD
T7622XS
Z134
Z1389
Z561
Z600
Z644
Z658
Z69010
Z69020
Z69021
Z736
Z73810
Z73811
Z73812
Z73819
Z8659
Z87820
Z87890
Z9183
S06890D
S06893A
S06895S
S069X0A
S069X2S
S069X5D
T5801XA
T5804XD
T5813XD
T582X2D
T588X2A
T5891XA
T5894XD
T71113S
T71122S
T71131S
T71141A
T71144S
T71153D
T71164A
T7121XA
T71233D
T7411XS
T7422XD
T7611XA
T7621XS
Z608
Z6982
Z781
S06890S
S06893D
S06896A
S069X0D
S069X3A
S069X5S
T5801XD
T5804XS
T5814XA
T582X3A
T588X2D
T5891XD
T71111A
T71114A
T71123A
T71132A
T71141D
T71151A
T71153S
T71191A
T71221A
T71234A
T7412XA
T7422XS
T7611XD
T7622XA
Z609
Z72810
Z818
S06891A
S06893S
S06896D
S069X0S
S069X3D
S069X6A
T5801XS
T5811XA
T5814XD
T582X3D
T588X3A
T5891XS
T71111D
T71114D
T71123D
T71133A
T71141S
T71151D
T71154A
T71192A
T71222A
T7129XA
T7412XD
T751XXA
T7611XS
T7622XD
Z634
Z72811
Z8651
S06335A,
S0190XA
S06365A,
S0190XA
S06375A,
S0190XA
S06385A,
S0190XA
S06336A,
S0190XA
S06366A,
S0190XA
S06376A,
S0190XA
S06386A,
S0190XA
S06339A,
S0190XA
S06369A,
S0190XA
S06379A,
S0190XA
S06389A,
S0190XA
* These diagnosis codes are only payable to procedure code 96118
Combination Diagnosis Codes (Must be submitted in pairs)
S06330A,
S06331A,
S06332A,
S06333A,
S06334A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06360A,
S06361A,
S06362A,
S06363A,
S06364A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06370A,
S06371A,
S06372A,
S06373A,
S06374A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06380A,
S06381A,
S06382A,
S06383A,
S06384A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
ICD-10 Special Bulletin, No. 8
89
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Combination Diagnosis Codes (Must be submitted in pairs)
S064X0A,
S064X1A,
S064X2A,
S064X3A,
S064X4A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S065X0A,
S065X1A,
S065X2A,
S065X3A,
S065X4A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S066X0A,
S066X1A,
S066X2A,
S066X3A,
S066X4A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06890A,
S060X0A
S064X5A,
S0190XA
S065X5A,
S0190XA
S066X5A,
S0190XA
S064X6A,
S0190XA
S065X6A,
S0190XA
S066X6A,
S0190XA
S064X9A,
S0190XA
S065X9A,
S0190XA
S066X9A,
S0190XA
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
Inpatient Behavioral Health Counseling/Psychotherapy and Psychiatric Diagnostic Interview
Diagnosis Codes
Inpatient psychotherapy and counseling procedure codes may be reimbursed when they are submitted with one of
the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390 *
F0391 *
F04
F05
F060
F061
F062
F0630
F0631
F0632
F0633
F0634
F064
F068
F070
F09
F1010
F10121
F1014
F10150
F10151
F10159
F10180
F10181
F10182
F10188
F1019
F1020
F1021
F10221
F10230
F10231
F10232
F10239
F1024
F10250
F10251
F10259
F1026
F10280
F10281
F10282
F10288
F1029
F10921
F1094
F10950
F10951
F10959
F1096
F10980
F10981
F10982
F10988
F1099
F1110
F11120
F11121
F1114
F11150
F11151
F11159
F11181
F11182
F11188
F1119
F1120
F1121
F11220
F11221
F11222
F11229
F1123
F1124
F11250
F11251
F11259
F11281
F11282
F11288
F1129
F11920
F11921
F11922
F11929
F1193
F1194
F11950
F11951
F11959
F11981
F11982
F11988
F1199
F1210
F12120
F12121
F12122
F12129
F12150
F12151
F12159
F12180
F12188
F1219
F1220
F1221
F12220
F12221
F12222
F12229
F12250
F12251
F12259
F12280
F12288
F1229
F12920
F12921
F12922
F12929
F12950
F12951
F12959
F12980
F12988
F1299
F13120
F13121
F13129
F1314
F13150
F13151
F13159
F13180
F13181
F13182
F13188
F1320
F1321
F13220
F13221
F13229
F13230
F13231
F13232
F13239
F1324
F13250
F13251
F13259
F1326
F13280
F13281
F13282
F13288
F13920
F13921
F13929
F13930
F13931
F13932
F13939
F1394
F13950
F13951
F13959
F1396
F13980
F13981
F13982
F13988
F1399
F1410
F14120
F14121
F14122
F14129
F1414
F14150
F14151
F14159
F14180
F14181
F14182
F14188
F1419
F1420
F1421
F14220
F14221
F14222
* These diagnosis codes are not payable to procedure codes 90791 and 90792.
ICD-10 Special Bulletin, No. 8
90
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F14229
F1423
F1424
F14250
F14251
F14282
F14288
F1429
F14920
F14921
F14950
F14951
F14959
F14980
F14981
F1510
F15120
F15121
F15122
F15129
F15159
F15180
F15181
F15182
F15188
F15220
F15221
F15222
F15229
F1523
F15259
F15280
F15281
F15282
F15288
F15922
F15929
F1593
F1594
F15950
F15981
F15982
F15988
F1599
F1610
F16129
F1614
F16150
F16151
F16159
F1619
F1620
F16220
F16221
F16229
F16259
F16280
F16283
F16288
F1629
F1694
F16950
F16951
F16959
F16980
F17208
F17209
F17218
F17219
F17228
F1810
F18120
F18121
F18129
F1814
F18180
F18188
F1819
F1820
F1821
F1824
F18250
F18251
F18259
F18280
F18921
F18929
F1894
F18950
F18951
F1899
F1910
F19120
F19121
F19122
F19151
F19159
F1916
F19180
F19181
F1920
F1921
F19220
F19221
F19222
F19232
F19239
F1924
F19250
F19251
F19281
F19282
F19288
F1929
F19920
F19931
F19932
F19939
F1994
F19950
F19980
F19981
F19982
F19988
F1999
F205
F2081
F209
F21
F22
F251
F258
F259
F29
F3010
F302
F303
F304
F309
F310
F3113
F312
F3130
F3131
F3132
F3161
F3162
F3163
F3164
F3173
F3177
F3178
F3181
F319
F320
F324
F325
F329
F330
F331
F3342
F339
F340
F341
F39
F4011
F40210
F40218
F40220
F40228
F40233
F40240
F40241
F40242
F40243
F40298
F408
F410
F411
F419
F4311
F4312
F4320
F4321
F4322
F438
F439
F440
F441
F444
F4481
F449
F450
F451
F4520
F4541
F4542
F458
F459
F481
F5000
F5001
F5002
F502
F508
F5103
F5104
F5105
F5109
F5111
F513
F514
F515
F518
F519
F14259
F14922
F14982
F1514
F1519
F1524
F1529
F15951
F16120
F16180
F1624
F16920
F16983
F17229
F18150
F18220
F18288
F18959
F19129
F19182
F19229
F19259
F19921
F19951
F200
F23
F3011
F3110
F314
F3174
F321
F332
F4001
F40230
F40248
F42
F4323
F445
F4521
F482
F509
F5112
F520
F14280
F14929
F14988
F15150
F1520
F15250
F15920
F15959
F16121
F16183
F16250
F16921
F16988
F17298
F18151
F18221
F1829
F18980
F1914
F19188
F19230
F1926
F19922
F19959
F201
F24
F3012
F3111
F315
F3175
F322
F333
F4002
F40231
F40290
F430
F4324
F446
F4522
F488
F5101
F5113
F521
F14281
F1494
F1499
F15151
F1521
F15251
F15921
F15980
F16122
F16188
F16251
F16929
F1699
F17299
F18159
F18229
F18920
F18988
F19150
F1919
F19231
F19280
F19930
F1996
F202
F250
F3013
F3112
F3160
F3176
F323
F3341
F4010
F40232
F40291
F4310
F4325
F447
F4529
F489
F5102
F5119
F5221
* These diagnosis codes are not payable to procedure codes 90791 and 90792.
ICD-10 Special Bulletin, No. 8
91
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F5222
F5231
F5232
F524
F525
F551
F553
F600
F602
F603
F607
F6081
F609
F630
F631
F6389
F639
F641
F642
F648
F652
F653
F654
F6551
F6552
F66
F6810
F6811
F6812
F6813
F73
F79
F800
F801
F802
F82
F840
F842
F845
F849
F908
F909
F911
F912
F913
F938
F939
F940
F941
F948
F959
F980
F981
F9821
F9829
G3184 *
G44209
G4720
G4721
G4722
G4726
G4727
G4729
R413
R41840
R41844
R4189
R45850
T7402XA
T7402XD
T7411XS
T7412XA
T7412XD
T7412XS
T7421XA
T7422XD
T7422XS
T7602XA
T7602XD
T7602XS
T7612XA
T7612XD
T7612XS
T7621XA
T7621XD
T7622XS
Z0389
Z561
Z600
Z608
Z634
Z635
Z638
Z644
Z655
Z69021
Z6982
Z72810
Z72811
Z736
F526
F604
F632
F649
F6581
F69
F809
F900
F918
F950
F983
G4723
R41841
T7402XS
T7421XD
T7611XA
T7621XS
Z609
Z658
Z781
F529
F605
F633
F650
F6589
F70
F8181
F901
F919
F951
F984
G4724
R41842
T7411XA
T7421XS
T7611XD
T7622XA
Z6331
Z69010
Z8651
F54
F606
F6381
F651
F659
F72
F819
F902
F930
F952
F989
G4725
R41843
T7411XD
T7422XA
T7611XS
T7622XD
Z6332
Z69020
Z9183
* These diagnosis codes are not payable to procedure codes 90791 and 90792.
Pharmacological Management
Pharmacological management services procedure codes M0064 may be reimbursed when they are submitted with
one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
F04
F05
F060
F061
F062
F0630
F0631
F0632
F0633
F0634
F064
F068
F070
F09
F1010
F10120
F10121
F10129
F1014
F10150
F10159
F10180
F10181
F10182
F10188
F1019
F1020
F1021
F10220
F10221
F10229
F10230
F10232
F10239
F1024
F10250
F10259
F10280
F10281
F10282
F10288
F1029
F10920
F10921
F10929
F1094
F10950
F10959
F10980
F10981
F10982
F10988
F1099
F1110
F11120
F11121
F1114
F11150
F11151
F11159
F11181
F11182
F11188
F1119
F1120
F1121
F11220
F11221
F11222
F11229
F1123
F1124
F11250
F11251
F11259
F11281
F11282
F11288
F1129
F11920
F11921
F11922
F11929
F1193
F1194
F11950
F11951
F11959
F11981
F11982
F11988
F1199
F1210
F12120
F12121
F12122
F12129
F12150
F12151
F12159
F12180
F12188
F1219
F1220
F1221
F12220
F12221
F12222
F12229
F12250
F12251
F12259
F12280
F12288
F1229
F12920
F12921
F12922
F12929
F12950
F12951
F12959
F12980
F12988
F1299
F1310
F13120
F13121
F13129
F1314
F13150
F13151
F13159
F13180
F13181
F13182
F13188
F1320
F1321
F13220
F13221
F13229
F13230
F13231
F13232
F13239
F1324
F13250
F13251
F13259
F1326
F13280
F13281
F13282
F13288
F13920
F13921
F13929
F13930
F13931
F13932
F13939
F1394
F13950
F13951
F13959
F1396
F13980
ICD-10 Special Bulletin, No. 8
92
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F13981
F13982
F13988
F1399
F1410
F14120
F14150
F14151
F14159
F14180
F14181
F14182
F14220
F14221
F14222
F14229
F1423
F1424
F14281
F14282
F14288
F1429
F14920
F14921
F14951
F14959
F14980
F14981
F14982
F14988
F15129
F1514
F15150
F15151
F15159
F15180
F1520
F1521
F15220
F15221
F15222
F15229
F15259
F15280
F15281
F15282
F15288
F1529
F1593
F1594
F15950
F15951
F15959
F15980
F1610
F16120
F16121
F16122
F16129
F1614
F16183
F16188
F1619
F1620
F16220
F16221
F16259
F16280
F16283
F16288
F1629
F16920
F16951
F16959
F16980
F16983
F16988
F1699
F17228
F17229
F17298
F17299
F1810
F18120
F18151
F18159
F18180
F18188
F1819
F1820
F1824
F18250
F18251
F18259
F18280
F18288
F1894
F18950
F18951
F18959
F18980
F18988
F19122
F19129
F1914
F19150
F19151
F19159
F19188
F1919
F1920
F1921
F19220
F19221
F19232
F19239
F1924
F19250
F19251
F19259
F19288
F1929
F19920
F19921
F19922
F19930
F19950
F19951
F19959
F1996
F19980
F19981
F201
F202
F205
F2081
F209
F21
F251
F258
F259
F29
F3010
F3011
F304
F309
F310
F3110
F3111
F3112
F3132
F314
F315
F3160
F3161
F3162
F3175
F3176
F3177
F3178
F3181
F319
F324
F325
F329
F330
F331
F332
F340
F341
F39
F4001
F4002
F4010
F40228
F40230
F40231
F40232
F40233
F40240
F40290
F40291
F40298
F408
F410
F411
F4311
F4312
F4320
F4321
F4322
F4323
F440
F441
F444
F445
F446
F447
F4520
F4521
F4522
F4529
F4541
F4542
F489
F5000
F5001
F5002
F502
F508
F5104
F5105
F5109
F5111
F5112
F5113
F518
F519
F520
F521
F5221
F5222
F526
F529
F54
F551
F553
F600
F605
F606
F607
F6081
F609
F630
F6389
F639
F641
F642
F648
F649
F654
F6551
F6552
F6581
F6589
F659
F6813
F69
F70
F72
F73
F79
F810
F812
F8181
F819
F82
F840
F908
F909
F911
F912
F913
F918
ICD-10 Special Bulletin, No. 8
93
F14121
F14188
F14250
F14922
F1499
F15181
F1523
F15920
F15981
F16150
F16229
F16921
F17208
F18121
F1821
F1829
F1899
F1916
F19222
F1926
F19931
F19982
F22
F3012
F3113
F3163
F320
F333
F4011
F40241
F419
F4324
F4481
F458
F509
F5119
F5231
F601
F631
F650
F66
F800
F843
F919
F14122
F1419
F14251
F14929
F15120
F15182
F1524
F15921
F15982
F16151
F1624
F16929
F17209
F18129
F18220
F18920
F1910
F19180
F19229
F19280
F19932
F19988
F23
F3013
F312
F3164
F321
F3341
F40210
F40242
F42
F4325
F449
F459
F5101
F513
F5232
F602
F632
F651
F6810
F801
F900
F930
F14129
F1420
F14259
F1494
F15121
F15188
F15250
F15922
F15988
F16159
F16250
F1694
F17218
F1814
F18221
F18921
F19120
F19181
F19230
F19281
F19939
F1999
F24
F302
F3130
F3173
F322
F3342
F40218
F40243
F430
F438
F450
F481
F5102
F514
F524
F603
F633
F652
F6811
F802
F901
F938
F1414
F1421
F14280
F14950
F15122
F1519
F15251
F15929
F1599
F16180
F16251
F16950
F17219
F18150
F18229
F18929
F19121
F19182
F19231
F19282
F1994
F200
F250
F303
F3131
F3174
F323
F339
F40220
F40248
F4310
F439
F451
F482
F5103
F515
F525
F604
F6381
F653
F6812
F804
F902
F939
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F940
F941
F948
F950
F951
F952
F9829
F983
F984
F989
G44209 G4720
G4725
G4726
G4727
G4729
R413
R41840
R4189
R45850
Z561
Z6331
Z6332
Z635
Z8651
Z9183
F959
G4721
R41841
Z638
F980
G4722
R41842
Z655
F981
G4723
R41843
Z658
F9821
G4724
R41844
Z781
Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management
Services Handbook, subsection 6.15, “Psychiatric Services for Hospitals,” for additional information.
Outpatient Behavioral Health
Outpatient behavioral health services may be reimbursed when services are performed in the office, home, skilled
nursing or intermediate care facility (SNF/ICF), outpatient hospital, extended care facility (ECF), or other location
when provided by one of the following provider types:
• Physician/psychiatrist (M.D. or D.O.)
• Advanced Practice Registered Nurse (APRN)
• Licensed Clinical Social Worker (LCSW)
• Physician Assistant (PA)
• Licensed Professional Counselor (LPC)
• Licensed Marriage and Family Therapist (LMFT)
• Licensed psychologist
• Licensed Psychological Associate (LPA) under the direct supervision of a psychologist in accordance with the
Texas State Board of Examiners of Psychologists (TSBEP)
• Provisionally Licensed Psychologist (PLP) under the direct supervision of a psychologist in accordance with the
TSBEP
Psychotherapy procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90847, 90853, and 90899 may
be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination
diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
G3184
R41841
Outpatient Behavioral Health Counseling/Psychotherapy and Psychiatric Diagnostic Interview
Diagnosis Codes
Psychiatric diagnostic evaluation procedure codes 90791 and 90792 and outpatient psychotherapy and counseling
procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis
codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
F04
F05
F060
F061
F062
F0630
F0631
F0632
F0633
F0634
F064
F068
F070
F09
ICD-10 Special Bulletin, No. 8
94
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F1010
F10121
F1014
F10150
F10151
F10182
F10188
F1019
F1020
F1021
F10232
F10239
F1024
F10250
F10251
F10281
F10282
F10288
F1029
F10921
F10959
F1096
F10980
F10981
F10982
F11120
F11121
F1114
F11150
F11151
F11188
F1119
F1120
F1121
F11220
F1123
F1124
F11250
F11251
F11259
F1129
F11920
F11921
F11922
F11929
F11951
F11959
F11981
F11982
F11988
F12121
F12122
F12129
F12150
F12151
F1219
F1220
F1221
F12220
F12221
F12251
F12259
F12280
F12288
F1229
F12929
F12950
F12951
F12959
F12980
F13121
F13129
F1314
F13150
F13151
F13182
F13188
F1320
F1321
F13220
F13231
F13232
F13239
F1324
F13250
F13280
F13281
F13282
F13288
F13920
F13931
F13932
F13939
F1394
F13950
F13980
F13981
F13982
F13988
F1399
F14122
F14129
F1414
F14150
F14151
F14182
F14188
F1419
F1420
F1421
F14229
F1423
F1424
F14250
F14251
F14282
F14288
F1429
F14920
F14921
F14950
F14951
F14959
F14980
F14981
F1510
F15120
F15121
F15122
F15129
F15159
F15180
F15181
F15182
F15188
F15220
F15221
F15222
F15229
F1523
F15259
F15280
F15281
F15282
F15288
F15922
F15929
F1593
F1594
F15950
F15981
F15982
F15988
F1599
F1610
F16129
F1614
F16150
F16151
F16159
F1619
F1620
F16220
F16221
F16229
F16259
F16280
F16283
F16288
F1629
F1694
F16950
F16951
F16959
F16980
F17208
F17209
F17218
F17219
F17228
F1810
F18120
F18121
F18129
F1814
F18180
F18188
F1819
F1820
F1821
F1824
F18250
F18251
F18259
F18280
F18921
F18929
F1894
F18950
F18951
F1899
F1910
F19120
F19121
F19122
F19151
F19159
F1916
F19180
F19181
F1920
F1921
F19220
F19221
F19222
F19232
F19239
F1924
F19250
F19251
ICD-10 Special Bulletin, No. 8
95
F10159
F10221
F10259
F1094
F10988
F11159
F11221
F11281
F1193
F1199
F12159
F12222
F12920
F12988
F13159
F13221
F13251
F13921
F13951
F1410
F14159
F14220
F14259
F14922
F14982
F1514
F1519
F1524
F1529
F15951
F16120
F16180
F1624
F16920
F16983
F17229
F18150
F18220
F18288
F18959
F19129
F19182
F19229
F19259
F10180
F10230
F1026
F10950
F1099
F11181
F11222
F11282
F1194
F1210
F12180
F12229
F12921
F1299
F13180
F13229
F13259
F13929
F13959
F14120
F14180
F14221
F14280
F14929
F14988
F15150
F1520
F15250
F15920
F15959
F16121
F16183
F16250
F16921
F16988
F17298
F18151
F18221
F1829
F18980
F1914
F19188
F19230
F1926
F10181
F10231
F10280
F10951
F1110
F11182
F11229
F11288
F11950
F12120
F12188
F12250
F12922
F13120
F13181
F13230
F1326
F13930
F1396
F14121
F14181
F14222
F14281
F1494
F1499
F15151
F1521
F15251
F15921
F15980
F16122
F16188
F16251
F16929
F1699
F17299
F18159
F18229
F18920
F18988
F19150
F1919
F19231
F19280
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F19281
F19282
F19288
F1929
F19920
F19931
F19932
F19939
F1994
F19950
F19980
F19981
F19982
F19988
F1999
F205
F2081
F209
F21
F22
F251
F258
F259
F29
F3010
F302
F303
F304
F309
F310
F3113
F312
F3130
F3131
F3132
F3161
F3162
F3163
F3164
F3173
F3177
F3178
F3181
F319
F320
F324
F325
F329
F330
F331
F3342
F339
F340
F341
F39
F4011
F40210
F40218
F40220
F40228
F40233
F40240
F40241
F40242
F40243
F40298
F408
F410
F411
F419
F4311
F4312
F4320
F4321
F4322
F438
F439
F440
F441
F444
F4481
F449
F450
F451
F4520
F4541
F4542
F458
F459
F481
F5000
F5001
F5002
F502
F508
F5103
F5104
F5105
F5109
F5111
F513
F514
F515
F518
F519
F5222
F5231
F5232
F524
F525
F551
F553
F600
F602
F603
F607
F6081
F609
F630
F631
F6389
F639
F641
F642
F648
F652
F653
F654
F6551
F6552
F66
F6810
F6811
F6812
F6813
F73
F79
F800
F801
F802
F82
F840
F842
F845
F849
F908
F909
F911
F912
F913
F938
F939
F940
F941
F948
F959
F980
F981
F9821
F9829
G3184
G44209
G4720
G4721
G4722
G4726
G4727
G4729
R413
R41840
R41844
R4189
R45850
T7402XA
T7402XD
T7411XS
T7412XA
T7412XD
T7412XS
T7421XA
T7422XD
T7422XS
T7602XA
T7602XD
T7602XS
T7612XA
T7612XD
T7612XS
T7621XA
T7621XD
T7622XS
Z0389
Z561
Z600
Z608
Z634
Z635
Z638
Z644
Z655
Z69021
Z6982
Z72810
Z72811
Z736
ICD-10 Special Bulletin, No. 8
96
F19921
F19951
F200
F23
F3011
F3110
F314
F3174
F321
F332
F4001
F40230
F40248
F42
F4323
F445
F4521
F482
F509
F5112
F520
F526
F604
F632
F649
F6581
F69
F809
F900
F918
F950
F983
G4723
R41841
T7402XS
T7421XD
T7611XA
T7621XS
Z609
Z658
Z781
F19922
F19959
F201
F24
F3012
F3111
F315
F3175
F322
F333
F4002
F40231
F40290
F430
F4324
F446
F4522
F488
F5101
F5113
F521
F529
F605
F633
F650
F6589
F70
F8181
F901
F919
F951
F984
G4724
R41842
T7411XA
T7421XS
T7611XD
T7622XA
Z6331
Z69010
Z8651
F19930
F1996
F202
F250
F3013
F3112
F3160
F3176
F323
F3341
F4010
F40232
F40291
F4310
F4325
F447
F4529
F489
F5102
F5119
F5221
F54
F606
F6381
F651
F659
F72
F819
F902
F930
F952
F989
G4725
R41843
T7411XD
T7422XA
T7611XS
T7622XD
Z6332
Z69020
Z9183
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Psychological and Neuropsychological Testing
Psychological testing procedure code 96101 and neuropsychological testing procedure code 96118 may be
reimbursed when they are submitted by a psychiatrist, psychologist, PLP, or LPA with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A8100
A8101
A8109
A8181
A8183
D8681
E7500
E7501
E7502
E7509
E7523
E7525
E7529
E754
F0390
F060
F061
F062
F0630
F0631
F064
F068
F070
F0781
F09
F10129
F1014
F10150
F10151
F10159
F10188
F1019
F1020
F1021
F10220
F10231
F10232
F10239 *
F1024
F10250
F10280
F10281
F10282
F10288
F1029
F1094
F10950
F10951
F10959
F1096
F10988
F1099
F1110
F11120
F11121
F11159
F11181
F11182
F11188
F1119
F11221
F11222
F11229
F1123
F1124
F11281
F11282
F11288
F1129
F11920
F1193
F1194
F11950
F11951
F11959
F1199
F1210
F12120
F12121
F12122
F12159
F12180
F12188
F1219
F1220
F12222
F12229
F12250
F12251
F12259
F12920
F12921
F12922
F12929
F12950
F12988
F1299
F1310
F13120
F13121
F13151
F13159
F13180
F13181
F13182
F13220
F13221
F13229
F13230
F13231
F13250
F13251
F13259
F1326
F13280
F13920
F13921
F13929
F13930
F13931
F13950
F13951
F13959
F1396
F13980
F1399
F1410
F14120
F14121
F14122
F14151
F14159
F14180
F14181
F14182
F1421
F14220
F14221
F14222
F14229
F14251
F14259
F14280
F14281
F14282
F14921
F14922
F14929
F1494
F14950
F14981
F14982
F14988
F1499
F1510
F15129
F1514
F15150
F15151
F15159
F15188
F1519
F1520
F1521
F15220
F1523
F1524
F15250
F15251
F15259
F15288
F1529
F15920
F15921
F15922
ICD-10 Special Bulletin, No. 8
97
B1001
E7510
F0391
F0632
F1010
F10180
F10221
F10251
F10920
F10980
F1114 *
F1120
F11250
F11921
F11981
F12129
F1221
F12280
F12951
F13129
F13188
F13232
F13281
F13932
F13981
F14129
F14188
F1423
F14288
F14951
F15120
F15180
F15221
F15280
F15929
B1009
E7511
F04
F0633
F10120
F10181
F10229
F10259
F10921
F10981
F11150
F1121
F11251
F11922
F11982
F12150
F12220
F12288
F12959
F1314
F1320
F13239
F13282
F13939
F13982
F1414
F1419
F1424
F1429
F14959
F15121
F15181
F15222
F15281
F1593
B451
E7519
F05
F0634
F10121
F10182
F10230
F1026
F10929
F10982
F11151
F11220
F11259
F11929
F11988
F12151
F12221
F1229
F12980
F13150
F1321
F1324
F13288
F1394
F13988
F14150
F1420
F14250
F14920
F14980
F15122
F15182
F15229
F15282
F1594
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F15950
F15951
F15959
F15980
F15981
F1610
F16120
F16121
F16122
F16129
F16159
F16180
F16183
F16188
F1619
F16229
F1624
F16250
F16251
F16259
F1629
F16920
F16921
F16929
F1694
F16980
F16983
F16988
F1699
F17208
F17228
F17229
F17298
F17299
F1810
F1814
F18150
F18151
F18159
F18180
F1821
F18220
F18221
F18229
F1824
F18280
F18288
F1829
F1890
F18920
F18950
F18951
F18959
F18980
F18988
F19121
F19122
F19129
F1914
F19150
F19180
F19181
F19182
F19188
F1919
F19221
F19222
F19229
F19230
F19231
F19250
F19251
F19259
F1926
F19280
F1929
F19920
F19921
F19922
F19929
F19939
F1994
F19950
F19951
F19959
F19982
F19988
F1999
F200
F201
F2081
F2089
F209
F21
F22
F251
F258
F259
F28
F29
F3013
F302
F303
F304
F308
F3111
F3112
F3113
F312
F3130
F315
F3160
F3161
F3162
F3163
F3175
F3176
F3177
F3178
F3181
F322
F323
F324
F325
F328
F332
F333
F3341
F3342
F339
F39
F4001
F4002
F4010
F4011
F40228
F40230
F40231
F40232
F40233
F40243
F40248
F40290
F40291
F40298
F411
F413
F418
F419
F42
F4312
F4320
F4321
F4322
F4323
F438
F439
F440
F441
F444
F4481
F4489
F449
F450
F451
F4529
F4541
F4542
F458
F459
F489
F5000
F5001
F5002
F502
F5102
F5103
F5104
F5105
F5109
F5119
F513
F514
F515
F518
F5221
F5222
F5231
F5232
F524
F54
F551
F553
F600
F601
ICD-10 Special Bulletin, No. 8
98
F15982
F1614
F1620
F16280
F16950
F17209
F18120
F18188
F18250
F18921
F1899
F19151
F1920
F19232
F19281
F19930
F1996
F202
F23
F3010
F309
F3131
F3164
F319
F329
F340
F40210
F40240
F408
F430
F4324
F445
F4520
F481
F508
F5111
F519
F525
F602
F15988
F16150
F16220
F16283
F16951
F17218
F18121
F1819
F18251
F18929
F1910
F19159
F1921
F19239
F19282
F19931
F19980
F203
F24
F3011
F310
F3132
F3173
F320
F330
F341
F40218
F40241
F409
F4310
F4325
F446
F4521
F482
F509
F5112
F520
F526
F603
F1599
F16151
F16221
F16288
F16959
F17219
F18129
F1820
F18259
F1894
F19120
F1916
F19220
F1924
F19288
F19932
F19981
F205
F250
F3012
F3110
F314
F3174
F321
F331
F348
F40220
F40242
F410
F4311
F4329
F447
F4522
F488
F5101
F5113
F521
F529
F604
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F605
F606
F607
F6081
F6089
F632
F633
F6381
F6389
F639
F649
F650
F651
F652
F653
F6581
F6589
F659
F66
F6810
F69
F70
F71
F72
F73
F802
F804
F8089
F809
F8181
F842
F843
F845
F849
F88
F908
F909
F911
F912
F913
F938
F939
F940
F941
F948
F959
F980
F981
F9821
F9829
G000
G001
G002
G003
G008
G030
G031
G038
G039
G0400
G0430
G0431
G0439
G0481
G0489
G054
G060
G061
G062
G07
G3182
G3184
G319
G3289
G35
G40019
G40101
G40109
G40111
G40119
G40219
G40301
G40309
G40311
G40319
G40804
G40811
G40813
G40821
G40822
G40901
G40909
G40911
G40919
G40A01
G44209
G450
G451
G454
G458
G4721
G4722
G4723
G4724
G4725
G910
G911
G912
G92
G930
G9349
G937
G9381
G9389
G939
H93293
I6001
I6002
I6011
I6012
I6032
I604
I6051
I6052
I606
I613
I614
I615
I616
I618
I6203
I621
I6300
I63011
I63012
I6309
I6310
I63111
I63112
I6312
I6320
I63211
I63212
I63231
I63232
I63321
I63322
I63331
I63332
I63341
I63412
I63421
I63422
I63431
I63432
I6350
I63511
I63512
I63519
I63521
I63532
I63539
I63541
I63542
I63549
I6503
I651
I6521
I6522
I6523
I6602
I6603
I6611
I6612
I6613
I663
I668
I669
I671
I672
I677
I6781
I6782
I6789
I679
I6901
I69020
I69021
I69022
I69023
I69033
I69034
I69041
I69042
I69043
ICD-10 Special Bulletin, No. 8
99
F609
F641
F654
F6811
F79
F819
F900
F918
F950
F983
G009
G0401
G0490
G210
G40001
G40201
G40801
G40823
G40A09
G459
G4726
G931
G94
I6021
I608
I6200
I6302
I63131
I6329
I63342
I63441
I63522
I6359
I658
I6621
I674
I680
I69028
I69044
F630
F642
F6551
F6812
F800
F82
F901
F919
F951
F984
G01
G0402
G0491
G3101
G40009
G40209
G40802
G40824
G40A11
G468
G4727
G9340
H93291
I6022
I610
I6201
I63031
I63132
I63311
I6339
I63442
I63529
I6501
I659
I6622
I675
I682
I69031
I69051
F631
F648
F6552
F6813
F801
F840
F902
F930
F952
F989
G02
G042
G053
G3181
G40011
G40211
G40803
G4089
G40A19
G4720
G4729
G9341
H93292
I6031
I611
I6202
I63032
I6319
I63312
I63411
I6349
I63531
I6502
I6601
I6623
I676
I688
I69032
I69052
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I69053
I69054
I69061
I69062
I69063
I69091
I69092
I69093
I69098
I6911
I69123
I69128
I69131
I69132
I69133
I69143
I69144
I69151
I69152
I69153
I69163
I69164
I69165
I69190
I69191
I6921
I69220
I69221
I69222
I69223
I69233
I69234
I69241
I69242
I69243
I69253
I69254
I69261
I69262
I69263
I69291
I69292
I69293
I69298
I6931
I69323
I69328
I69331
I69332
I69333
I69343
I69344
I69351
I69352
I69353
I69363
I69364
I69365
I69390
I69391
I6981
I69820
I69821
I69822
I69823
I69833
I69834
I69841
I69842
I69843
I69853
I69854
I69861
I69862
I69863
I69891
I69892
I69893
I69898
I69951
I69961
I69962
I69963
I69964
I69965
P521
P5221
P5222
P523
P525
R0902
R413
R41840
R41841
R41842
R450
R453
R454
R457
R45850
R4589
R5600
R5601
R569
S060X0A
S060X1D
S060X1S
S060X2A
S060X2D
S060X2S
S060X4A
S060X4D
S060X4S
S060X5A
S060X5D
S060X6S
S060X9A
S060X9D
S060X9S
S06306D
S06310S
S06311A
S06311D
S06311S
S06312A
S06313D
S06313S
S06314A
S06314D
S06314S
S06316A
S06316D
S06316S
S06319A
S06319D
S06320S
S06321A
S06321D
S06321S
S06322A
S06323D
S06323S
S06324A
S06324D
S06324S
S06326A
S06326D
S06326S
S06329A
S06329D
S06330S
S06331A
S06331D
S06331S
S06332A
S06333D
S06333S
S06334A
S06334D
S06334S
S06336A
S06336D
S06339A
S06339D
S06339S
S06341A
S06341D
S06341S
S06342A
S06342D
S06343S
S06344A
S06344D
S06344S
S06345A
S06346D
S06346S
S06349A
S06349D
S06349S
S06351D
S06351S
S06352A
S06352D
S06352S
S06354A
S06354D
S06354S
S06355A
S06355D
S06356S
S06359A
S06359D
S06359S
S06360A
ICD-10 Special Bulletin, No. 8
100
I69064
I69120
I69134
I69154
I69192
I69228
I69244
I69264
I69320
I69334
I69354
I69392
I69828
I69844
I69864
I69952
P102
P84
R41843
R45851
S060X0D
S060X3A
S060X5S
S06306S
S06312D
S06315A
S06319S
S06322D
S06325A
S06329S
S06332D
S06335A
S06340A
S06342S
S06345D
S06350A
S06353A
S06355S
S06360D
I69065
I69121
I69141
I69161
I69193
I69231
I69251
I69265
I69321
I69341
I69361
I69393
I69831
I69851
I69865
I69953
P103
P90
R41844
R4586
S060X0S
S060X3D
S060X6A
S06310A
S06312S
S06315D
S06320A
S06322S
S06325D
S06330A
S06332S
S06335D
S06340D
S06343A
S06345S
S06350S
S06353D
S06356A
S06360S
I69090
I69122
I69142
I69162
I69198
I69232
I69252
I69290
I69322
I69342
I69362
I69398
I69832
I69852
I69890
I69954
P520
R0901
R4189
R4587
S060X1A
S060X3S
S060X6D
S06310D
S06313A
S06315S
S06320D
S06323A
S06325S
S06330D
S06333A
S06335S
S06340S
S06343D
S06346A
S06351A
S06353S
S06356D
S06361A
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S06361D
S06361S
S06362A
S06362D
S06362S
S06364A
S06364D
S06364S
S06365A
S06365D
S06366S
S06369A
S06369D
S06369S
S06370A
S06371D
S06371S
S06372A
S06372D
S06372S
S06374A
S06374D
S06374S
S06375A
S06375D
S06376S
S06379A
S06379D
S06379S
S06380A
S06381D
S06381S
S06382A
S06382D
S06382S
S06384A
S06384D
S06384S
S06385A
S06385D
S06386S
S06389A
S06389D
S06389S
S064X0A
S064X1D
S064X1S
S064X2A
S064X2D
S064X2S
S064X4A
S064X4D
S064X4S
S064X5A
S064X5D
S064X6S
S064X9A
S064X9D
S064X9S
S065X0A
S065X1D
S065X1S
S065X2A
S065X2D
S065X2S
S065X4A
S065X4D
S065X4S
S065X5A
S065X5D
S065X6S
S065X9A
S065X9D
S065X9S
S066X0A
S066X1D
S066X1S
S066X2A
S066X2D
S066X2S
S066X4A
S066X4D
S066X4S
S066X5A
S066X5D
S066X6S
S066X9A
S066X9D
S066X9S
S06890A
S06891D
S06891S
S06892A
S06892D
S06892S
S06894A
S06894D
S06894S
S06895A
S06895D
S06896S
S06897S
S06899A
S06899D
S06899S
S069X1A
S069X1D
S069X1S
S069X2A
S069X2D
S069X3S
S069X4A
S069X4D
S069X4S
S069X5A
S069X6D
S069X6S
S069X9A
S069X9D
S069X9S
T5802XA
T5802XD
T5803XA
T5803XD
T5804XA
T5811XD
T5811XS
T5812XA
T5812XD
T5813XA
T5814XS
T582X1A
T582X1D
T582X1S
T582X2A
T582X4A
T582X4D
T588X1A
T588X1D
T588X1S
T588X3D
T588X3S
T588X4A
T588X4D
T588X4S
T5892XA
T5892XD
T5893XA
T5893XD
T5894XA
T71111S
T71112A
T71112S
T71113A
T71113D
T71114S
T71121A
T71121D
T71121S
T71122A
T71123S
T71124A
T71124S
T71131A
T71131D
T71133S
T71134A
T71134D
T71134S
T71141A
T71143D
T71143S
T71144A
T71144D
T71144S
T71152A
T71152D
T71152S
T71153A
T71153D
T71154S
T71161A
T71162A
T71163A
T71164A
T71194A
T71194D
T71194S
T7120XA
T7121XA
T71224A
T71231A
T71232A
T71233A
T71233D
ICD-10 Special Bulletin, No. 8
101
S06363A
S06365S
S06370D
S06373A
S06375S
S06380D
S06383A
S06385S
S064X0D
S064X3A
S064X5S
S065X0D
S065X3A
S065X5S
S066X0D
S066X3A
S066X5S
S06890D
S06893A
S06895S
S069X0A
S069X2S
S069X5D
T5801XA
T5804XD
T5813XD
T582X2D
T588X2A
T5891XA
T5894XD
T71113S
T71122S
T71131S
T71141D
T71151A
T71153S
T71191A
T71221A
T71234A
S06363D
S06366A
S06370S
S06373D
S06376A
S06380S
S06383D
S06386A
S064X0S
S064X3D
S064X6A
S065X0S
S065X3D
S065X6A
S066X0S
S066X3D
S066X6A
S06890S
S06893D
S06896A
S069X0D
S069X3A
S069X5S
T5801XD
T5804XS
T5814XA
T582X3A
T588X2D
T5891XD
T71111A
T71114A
T71123A
T71132A
T71141S
T71151D
T71154A
T71192A
T71222A
T7129XA
S06363S
S06366D
S06371A
S06373S
S06376D
S06381A
S06383S
S06386D
S064X1A
S064X3S
S064X6D
S065X1A
S065X3S
S065X6D
S066X1A
S066X3S
S066X6D
S06891A
S06893S
S06896D
S069X0S
S069X3D
S069X6A
T5801XS
T5811XA
T5814XD
T582X3D
T588X3A
T5891XS
T71111D
T71114D
T71123D
T71133D
T71143A
T71151S
T71154D
T71193A
T71223A
T7402XA
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T7402XD
T7402XS
T7411XA
T7411XD
T7411XS
T7421XA
T7421XD
T7421XS
T7422XA
T7422XD
T751XXS
T7602XA
T7602XD
T7602XS
T7611XA
T7612XD
T7612XS
T7621XA
T7621XD
T7621XS
Z134
Z1389
Z561
Z600
Z608
Z658
Z69010
Z69020
Z69021
Z6982
Z73810
Z73811
Z73812
Z73819
Z781
Z87820
Z87890
Z9183
Combination Diagnosis Codes (Must be submitted in pairs)
S06330A,
S06331A,
S06332A,
S06333A,
S06334A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06360A,
S06361A,
S06362A,
S06363A,
S06364A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06370A,
S06371A,
S06372A,
S06373A,
S06374A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06380A,
S06381A,
S06382A,
S06383A,
S06384A,
S0190XA
S0190XA
S0190XA
S0190XA
S0190XA
S06890A,
S064X0A,
S064X1A,
S064X2A,
S065X2A,
S060X0A
S0190XA
S0190XA
S0190XA
S0190XA
S065X6A,
S065X9A,
S066X0A,
S066X1A,
S066X2A,
S0190XA
S0190XA
S0190XA
S090XA
S0190XA
S066X6A,
S066X9A,
S0190XA
S0190XA
T7412XA
T7422XS
T7611XD
T7622XA
Z609
Z72810
Z818
T7412XD
T751XXA
T7611XS
T7622XD
Z634
Z72811
Z8651
T7412XS
T751XXD
T7612XA
T7622XS
Z644
Z736
Z8659
S06335A,
S0190XA
S06365A,
S0190XA
S06375A,
S0190XA
S06385A,
S0190XA
S065X3A,
S0190XA
S066X3A,
S0190XA
S06336A,
S0190XA
S06366A,
S0190XA
S06376A,
S0190XA
S06386A,
S0190XA
S065X4A,
S0190XA
S066X4A,
S0190XA
S06339A,
S0190XA
S06369A,
S0190XA
S06379A,
S0190XA
S06389A,
S0190XA
S065X5A,
S0190XA
S066X5A,
S0190XA
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
Pharmacological Regimen Oversight and Pharmacological Management
Pharmacological regimen oversight services may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
F04
F05
F060
F061
F062
F0630
F0631
F0632
F0633
F0634
F064
F068
F070
F09
F1010
F10120
F10121
F10129
F1014
F10150
F10159
F10180
F10181
F10182
F10188
F1019
F1020
F1021
F10220
F10221
F10229
F10230
F10232
F10239
F1024
F10250
F10259
F10280
F10281
F10282
F10288
F1029
F10920
F10921
F10929
F1094
F10950
F10959
F10980
F10981
F10982
F10988
F1099
F1110
F11120
F11121
F1114
F11150
F11151
F11159
F11181
F11182
F11188
F1119
F1120
F1121
F11220
F11221
F11222
F11229
F1123
F1124
F11250
F11251
F11259
F11281
F11282
F11288
F1129
F11920
F11921
F11922
F11929
F1193
F1194
F11950
F11951
F11959
F11981
F11982
F11988
F1199
F1210
F12120
F12121
F12122
F12129
F12150
ICD-10 Special Bulletin, No. 8
102
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F12151
F12159
F12180
F12188
F1219
F1220
F12229
F12250
F12251
F12259
F12280
F12288
F12929
F12950
F12951
F12959
F12980
F12988
F13129
F1314
F13150
F13151
F13159
F13180
F1321
F13220
F13221
F13229
F13230
F13231
F13251
F13259
F1326
F13280
F13281
F13282
F13930
F13931
F13932
F13939
F1394
F13950
F13981
F13982
F13988
F1399
F1410
F14120
F14150
F14151
F14159
F14180
F14181
F14182
F14220
F14221
F14222
F14229
F1423
F1424
F14281
F14282
F14288
F1429
F14920
F14921
F14951
F14959
F14980
F14981
F14982
F14988
F15129
F1514
F15150
F15151
F15159
F15180
F1520
F1521
F15220
F15221
F15222
F15229
F15259
F15280
F15281
F15282
F15288
F1529
F1593
F1594
F15950
F15951
F15959
F15980
F1610
F16120
F16121
F16122
F16129
F1614
F16183
F16188
F1619
F1620
F16220
F16221
F16259
F16280
F16283
F16288
F1629
F16920
F16951
F16959
F16980
F16983
F16988
F1699
F17228
F17229
F17298
F17299
F1810
F18120
F18151
F18159
F18180
F18188
F1819
F1820
F1824
F18250
F18251
F18259
F18280
F18288
F1894
F18950
F18951
F18959
F18980
F18988
F19122
F19129
F1914
F19150
F19151
F19159
F19188
F1919
F1920
F1921
F19220
F19221
F19232
F19239
F1924
F19250
F19251
F19259
F19288
F1929
F19920
F19921
F19922
F19930
F19950
F19951
F19959
F1996
F19980
F19981
F201
F202
F205
F2081
F209
F21
F251
F258
F259
F29
F3010
F3011
F304
F309
F310
F3110
F3111
F3112
F3132
F314
F315
F3160
F3161
F3162
F3175
F3176
F3177
F3178
F3181
F319
F324
F325
F329
F330
F331
F332
F340
F341
F39
F4001
F4002
F4010
F40228
F40230
F40231
F40232
F40233
F40240
F40290
F40291
F40298
F408
F410
F411
F4311
F4312
F4320
F4321
F4322
F4323
F440
F441
F444
F445
F446
F447
F4520
F4521
F4522
F4529
F4541
F4542
F489
F5000
F5001
F5002
F502
F508
F5104
F5105
F5109
F5111
F5112
F5113
F518
F519
F520
F521
F5221
F5222
ICD-10 Special Bulletin, No. 8
103
F1221
F1229
F1299
F13181
F13232
F13288
F13951
F14121
F14188
F14250
F14922
F1499
F15181
F1523
F15920
F15981
F16150
F16229
F16921
F17208
F18121
F1821
F1829
F1899
F1916
F19222
F1926
F19931
F19982
F22
F3012
F3113
F3163
F320
F333
F4011
F40241
F419
F4324
F4481
F458
F509
F5119
F5231
F12220
F12920
F1310
F13182
F13239
F13920
F13959
F14122
F1419
F14251
F14929
F15120
F15182
F1524
F15921
F15982
F16151
F1624
F16929
F17209
F18129
F18220
F18920
F1910
F19180
F19229
F19280
F19932
F19988
F23
F3013
F312
F3164
F321
F3341
F40210
F40242
F42
F4325
F449
F459
F5101
F513
F5232
F12221
F12921
F13120
F13188
F1324
F13921
F1396
F14129
F1420
F14259
F1494
F15121
F15188
F15250
F15922
F15988
F16159
F16250
F1694
F17218
F1814
F18221
F18921
F19120
F19181
F19230
F19281
F19939
F1999
F24
F302
F3130
F3173
F322
F3342
F40218
F40243
F430
F438
F450
F481
F5102
F514
F524
F12222
F12922
F13121
F1320
F13250
F13929
F13980
F1414
F1421
F14280
F14950
F15122
F1519
F15251
F15929
F1599
F16180
F16251
F16950
F17219
F18150
F18229
F18929
F19121
F19182
F19231
F19282
F1994
F200
F250
F303
F3131
F3174
F323
F339
F40220
F40248
F4310
F439
F451
F482
F5103
F515
F525
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F526
F529
F54
F551
F553
F600
F605
F606
F607
F6081
F609
F630
F6389
F639
F641
F642
F648
F649
F654
F6551
F6552
F6581
F6589
F659
F6813
F69
F70
F72
F73
F79
F810
F812
F8181
F819
F82
F840
F908
F909
F911
F912
F913
F918
F940
F941
F948
F950
F951
F952
F9829
F983
F984
F989
G44209 G4720
G4725
G4726
G4727
G4729
R413
R41840
R4189
R45850
Z561
Z6331
Z6332
Z635
Z8651
Z9183
F601
F631
F650
F66
F800
F843
F919
F959
G4721
R41841
Z638
F602
F632
F651
F6810
F801
F900
F930
F980
G4722
R41842
Z655
F603
F633
F652
F6811
F802
F901
F938
F981
G4723
R41843
Z658
F604
F6381
F653
F6812
F804
F902
F939
F9821
G4724
R41844
Z781
Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management
Services Handbook, subsection 6.4, “Outpatient Behavioral Health Services,” for more information.
Substance Use Disorder Services (Abuse and Dependence)
Procedure codes H0004 and H0005 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F1010
F10120
F10129
F10159
F10188
F1019
F1020
F1021
F10220
F10229
F10230
F10232
F10239
F10259
F10281
F10288
F1029
F10920
F10929
F10959
F10988
F1099
F1110
F11120
F11159
F11181
F11182
F11188
F1119
F1120
F1121
F11220
F11222
F11229
F11259
F11281
F11282
F11288
F1129
F11920
F11922
F11929
F11959
F11981
F11982
F11988
F1199
F1210
F12120
F12122
F12129
F12159
F12180
F12188
F1219
F1220
F1221
F12220
F12222
F12229
F12259
F12280
F12288
F1229
F12920
F12922
F12929
F12959
F12980
F12988
F1299
F13120
F13129
F13159
F13180
F13181
F13182
F13188
F1320
F1321
F13220
F13229
F13259
F13280
F13281
F13282
F13288
F13920
F13929
F13959
F13980
F13981
F13982
F13988
F1399
F1410
F14120
F14122
F14129
F14159
F14180
F14181
F14182
F14188
F1419
F1420
F1421
F14220
F14222
F14229
F14259
F14280
F14281
F14282
F14288
F1429
F14920
F14922
F14929
F14959
F14980
F14981
F14982
F14988
F1499
F1510
F15120
F15122
F15129
F15159
F15180
F15181
F15182
F15188
F1519
F1520
F1521
F15220
F15222
F15229
F15259
F15280
F15281
F15282
F15288
F1529
F15920
F15922
F15929
F15959
F15980
F15981
F15982
F15988
F1599
F1610
F16120
F16122
F16129
F16159
F16180
F16183
F16188
F1619
F1620
F16220
F16229
F16259
F16280
F16283
F16288
F1629
F16920
F16929
F16959
F16980
F16983
F16988
F1699
F17208
F17209
F17218
F17219
F17228
F17229
F17298
F17299
F1810
F18120
F18129
F18159
F18180
F18188
F1819
F1820
F1821
F18220
F18229
F18259
F18280
F18288
F1829
F18920
F18929
F18959
F18980
F18988
F1899
F1910
F19120
F19122
F19129
F19159
F19180
F19181
F19182
F19188
F1919
F1920
F1921
F19220
F19222
F19229
F19259
F19280
F19281
F19282
F19288
F1929
F19920
F19922
F19929
F19959
F19980
F19981
F19982
F19988
F1999
F551
F553
ICD-10 Special Bulletin, No. 8
104
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CPT only copyright 2014 American Medical Association. All rights reserved.
Behavioral Health Services
Medication Assisted Therapy (MAT)
Medication-assisted therapy (MAT) services may be considered on appeal for reimbursement on the same date of
service as residential detoxification and residential treatment services for pregnant women with an opioid addiction,
or for clients in current MAT treatment for an opioid addiction who are also receiving residential services for a
substance other than opioids.
For Medication Assisted Therapy (MAT) in the scenarios below, one of each of the following opioid, non-opioid,
and pregnancy diagnoses must be submitted on the claim.
Opioid MAT Diagnosis Codes
Diagnosis Codes
F1120, F1121, F11220, F11221, F11222, F11229, F1123,
F1124, F11259, F11281, F11282, F11288, F1129
F1821, F1920, F1921
F1110
Description
Opioid type dependence
Combination of opioid type drug
Opioid abuse
Non-Opioid MAT/Pregnancy Diagnosis Codes
Diagnosis Codes
F1020, F1021
F1320, F1321
F1420, F1421
F1520, F1521
F1620, F1621
F1620, F1820, F1821, F1920, F1921
F15120, F15129, F15220, F15229, F15920, F15929,
F1610, F1810, F1890, F1910, F551, F553
O99320, O99321, O99322, O99323, O99325
Description
Other and unspecified alcohol dependence
Sedative, hypnotic or anxiolytic dependence
Cocaine dependence
Amphetamine and other psychostimulant dependence
Hallucinogen dependence
Other or unspecified drug dependence
Other, mixed, or unspecified drug abuse
Pregnancy
The diagnosis for admission criteria for residential treatment services must meet the definition of chemical dependence, as detailed in the most current revision of the ICD-CM, or the most current revision of the Diagnostic
and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have
persisted for at least one month or have occurred repeatedly over a longer period of time.
Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management
Services Handbook, Section 8, “Substance Use Disorder (SUD) Services (Abuse and Dependence),” for
additional information.
ICD-10 Special Bulletin, No. 8
105
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Texas Health Steps (THSteps) Medical Providers
TEXAS HEALTH STEPS (THSTEPS) MEDICAL PROVIDERS
THSteps Medical Benefit Changes
The following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are
effective for dates of service on or after October 1, 2015.
For questions, call the TMHP Contact Center at 1-800-925-9126.
Texas Health Steps (THSteps) Environmental Lead Investigations
Procedure code T1029 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
T560X1A
T560X1D
T560X1S
T560X2A
T560X2D
T560X2S
T560X3A
T560X3D
T560X3S
T560X4A
T560X4D
T560X4S
Z77011
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, Appendix C.4 “Environmental Lead Investigation Services,” for additional information.
Texas Health Steps (THSteps) Preventive Care Medical Checkups
ICD-10-CM diagnosis codes Z00121 and Z00129 replace ICD-9-CM diagnosis code V202 for medical checkups,
exception to periodicity checkups, and follow-up visits.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, Subsection 5.5.1, “Claims
Information,” for additional information.
If an acute or chronic condition requiring evaluation and management (E/M) beyond the required components for
a medical checkup is discovered, a separate E/M procedure code may be considered for the same date of service as a
checkup or the client can be referred for further diagnosis and treatment. The client’s medical record must contain
documentation that the separate identifiable service(s) were medically necessary and include a diagnosis other than
Z00121 or Z00129. Documentation must be made available to Texas Medicaid upon request.
The administration of an immunization at the time of a checkup is billed with diagnosis code Z00121 or Z00129
unless a more appropriate diagnosis code is available.
For oral evaluation and fluoride varnish in the medical home (OEFV), procedure code 99429 may be reimbursed
when it is billed with diagnosis code Z00121 or Z00129.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 5.3.4, “THSteps
Medical Checkups,” for additional information.
ICD-10 Special Bulletin, No. 8
106
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Texas Health Steps (THSteps) Dental Providers
TEXAS HEALTH STEPS (THSTEPS) DENTAL PROVIDERS
THSteps Dental Benefit Changes
The following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are
effective for dates of service on or after October 1, 2015.
For questions, call the TMHP Contact Center at 1-800-925-9126.
Texas Health Steps (THSteps) Therapeutic Dental Services
Dental behavior management procedure code D9920 may be reimbursed when the client has a diagnosis of an
intellectual disability described as mild, moderate, severe, profound, or unspecified. The most appropriate ICD-10
diagnosis code for mild, moderate, severe, profound, or unspecified intellectual disability must be included on the
claim.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 4.2.23, “Adjunctive General Services,” for additional information.
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Home Health Providers
HOME HEALTH PROVIDERS
Home Health Benefit Changes
The following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are
effective for dates of service on or after October 1, 2015.
Diabetic Equipment and Supplies – Home Health
Diabetic equipment and supplies may be reimbursed without prior authorization when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diabetic and non-diabetic diagnosis codes:
Diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E0800
E0801
E0810
E0811
E0821
E0822
E0829
E08311
E08319
E08321
E08329
E08331
E08339
E08341
E08349
E08351
E08359
E0836
E0839
E0840
E0841
E0842
E0843
E0844
E0849
E0851
E0859
E08610
E08618
E08620
E08621
E08622 E08628 E08630 E08638 E08641 E08649 E0865
E0869
E088
E089
E0900
E0901
E0910
E0911
E0921
E0922
E0929
E09311
E09319
E09321
E09329
E09331
E09339
E09341
E09349
E09351
E09359
E0936
E0939
E0940
E0941
E0942
E0943
E0944
E0949
E0951
E0959
E09610
E09618
E09620 E09621
E09622 E09628 E09630 E09638
E09641 E09649 E0965
E0969
E098
E099
E1010
E1011
E1021
E1022
E1029
E10311
E10319
E10321
E10329
E10331
E10339
E10341
E10349
E10351
E10359
E1036
E1039
E1040
E1041
E1042
E1043
E1044
E1049
E1051
E1052
E1059
E10610
E10618
E10620
E10621
E10622
E10628
E10630
E10638
E10641
E10649
E1065
E1069
E108
E109
E1100
E1101
E1121
E1122
E1129
E11311
E11319
E11321
E11329
E11331
E11339
E11341
E11349
E11351
E11359
E1136
E1139
E1140
E1141
E1142
E1143
E1144
E1149
E1151
E1152
E1159
E11610
E11618
E11620
E11621
E11622
E11628
E11630
E11638
E11641
E11649
E1165
E1169
E118
E119
E1300
E1301
E1310
E1311
E1321
E1322
E1329
E13311
E13319
E13321
E13329
E13331
E13339
E13341
E13349
E13351
E13359
E1336
E1339
E1340
E1341
E1342
E1343
E1344
E1349
E1351
E1352
E1359
E13610
E13620
E13621
E13622
E13628
E13638
E13641
E13649
E1365
E1369
E138
E139
O24011 O24012 O24013 O2402
O2403
O24414 O24424 O24434
O99810 O99814 O99815 P702
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
E0800,
E0801,
E0821,
E08311,
E08319,
E0865
E0865
E0865
E0865
E0865
E08339,
E08341,
E08349,
E08351,
E08359,
E0865
E0865
E0865
E0865
E0865
E0865,
E0865,
E0865,
E0865,
E0865,
E0841
E0842
E0843
E0844
E0849
E0865,
E0865,
E0865,
E0865,
E0865,
E0869
E088
E0921
E09311
E09319
ICD-10 Special Bulletin, No. 8
108
E08321,
E0865
E0836,
E0865
E0865,
E0851
E0865,
E0936
E08329,
E0865
E0839,
E0865
E0865,
E0852
E0865,
E0940
E08331,
E0865
E0840,
E0865
E0865,
E0859
E0865,
E0951
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Home Health Providers
Combination Diagnosis Codes (Must be submitted in pairs)
E0865,
E0865,
E0865,
E0865,
E0900,
E0969
E098
E1365
E138
E0865
E1011,
E1011,
E1011,
E10319,
E1036,
E1065
E1311
E13641
E1065
E1065
E1065,
E1065,
E1065,
E1065,
E1065,
E1021
E1022
E1029
E10311
E10321
E1065,
E1065,
E1065,
E1065,
E1065,
E10341
E10349
E10351
E10359
E1041
E1065,
E1065,
E1065,
E1065,
E1065,
E1049
E1052
E1059
E10610
E1069
E1065,
E1065,
E1065,
E1065,
E1065,
E1143
E1144
E1149
E11610
E1340
E1065,
E1065,
E1065,
E1100,
E1101,
E1344
E1349
E13610
E1165
E1165
E1121,
E1121,
E1121,
E11311,
E11319,
E1321
E1322
E1329
E1165
E1165
E1151,
E1165,
E1165,
E1321,
E1165
E1169
E118
E0865
E0901,
E0865
E1039,
E1065
E1065,
E10329
E1065,
E1042
E1065,
E108
E1065,
E1341
E1121,
E1122
E1136,
E1165
E1010,
E1065
E1040,
E1065
E1065,
E10331
E1065,
E1043
E1065,
E1141
E1065,
E1342
E1121,
E1129
E1139,
E1165
E1011,
E10641
E1051,
E1065
E1065,
E10339
E1065,
E1044
E1065,
E1142
E1065,
E1343
E1121,
E1165
E1140,
E1165
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Non-diabetic Diagnosis Codes
Non-diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E161
E162
E71111
E71310
E71311
E71312
E71313
E7132
E7420
E7421
E7429
E8881
K911
R7309
E71314
R81
E71318
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.11,” Diabetic Equipment and Supplies;” and subsection 2.2.11.3,
“Glucose Testing Equipment and Other Supplies,” for additional information.
Incontinence Supplies – Home Health
A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician
Order Form for intermittent catheters and related insertion supplies may be granted for up to 12 months for
quantities within the stated benefit limits for clients with certain chronic conditions.
The prior authorization request must include one of the following ICD-10-CM diagnosis codes to describe the
client’s chronic condition:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G35
G8221
G8222
G8250
G8253
G8254
G834
N310
N311
N312
N319
Q054
Q057
Q058
Q0701
Q0702
Q0703
Q6410
Q6412
Q6419
Q760
Q794
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Home Health Providers
Diagnosis codes R32 and R339 are not specific enough to allow for the extension of the prior authorization to
12 months.
Refer to: The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.13, “Incontinence Supplies,” for additional information.
Respiratory Equipment and Supplies–Home Health
Nebulizers
Nebulizer and nebulizer supplies may be reimbursed without prior authorization when they are submitted with one
of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B59
E840
E8411
E8419
E848
E849
J09X1
J09X2
J121
J1281
J15212
J188
J189
J210
J211
J218
J219
J410
J411
J418
J430
J431
J432
J438
J439
J440
J441
J449
J4520
J42
J471
J45991
J45998
J45909
J45990
J45902
J4550
J45901
J4530
J4540
J479
J670
J671
J672
J673
J674
J675
J676
J677
J678
J679
J690
J691
J698
K449
P270
P271
P278
Purchase of nebulizers for diagnoses other than those listed in the above table may be considered for prior authorization when the request is submitted with documentation of medical necessity.
Ultrsonic nebulizers may be considered for prior authorization when the request is submitted with one of the
following ICD-10-CM diagnosis codes and documentation of failure of standard therapy:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B59
E840
E8411
E8419
E848
E849
J09X1
The rental of an intermittent positive-pressure breathing (IPPB) device may be prior authorized when the request is
submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
449
G7111
J84111
J84848
E840
G7112
J84112
J951
E8411
G7113
J84113
J952
E8419
G7114
J84114
J953
E848
G7119
J84115
J95821
E849
J09X1
J84116
J95822
G121
J182
J84117
G128
J811
J842
G129
J8402
J84842
G710
J8410
J84843
The mucous clearance valve may be prior authorized when the request is submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8411
E8419
E848
E849
J09X1
J40
J410
J411
J418
J42
J430
J431
J432
J438
J439
J441
J449
J4520
J4521
J4522
J4530
J4531
J4532
J4540
J4541
J4542
J4550
J4551
J4552
J45901
J45902
J45909
J45990
J45991
J45998
J471
J479
J670
J671
J672
J673
J674
J675
J676
J677
J678
J679
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CPT only copyright 2014 American Medical Association. All rights reserved.
Comprehensive Care Program (CCP) Providers
Prior authorization of the high-frequency chest wall compression system (HFCWCS) may be considered when the
request is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
G801
J09X1
E8411
G802
J8410
E8419
G804
E848
G808
E849
G809
G121
G8381
G128
G8382
G129
G8383
G710
G8384
G800
G8389
Refer to: The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, Section 2, “Texas Medicaid (Title XIX) Home Health Services;” subsection 2.2,
“Services, Benefits, Limitations and Prior Authorization;” subsection 2.2.13.6.2, “Intermittent Catheters and
Related Insertion Supplies;” and subsection 2.2.19, “Respiratory Equipment and Supplies,” for additional
information.
COMPREHENSIVE CARE PROGRAM (CCP) PROVIDERS
CCP Benefit Changes
The following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are
effective for dates of service on or after October 1, 2015.
Blood Pressure Devices - CCP
Manual and automated blood pressure devices may be reimbursed without prior authorization when they are
submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I10
I110
I119
I120
I129
I130
I151
I152
I158
I159
I2601
I2602
I270
I271
I2781
I2782
I2789
I279
I349
I350
I351
I352
I358
I359
I369
I370
I371
I372
I378
I379
I428
I429
I43
I440
I441
I442
I4460
I4469
I447
I450
I4510
I4519
I456
I4581
I4589
I459
I471
I472
I483
I484
I4891
I4892
I495
I501
I5030
I5031
I5032
I5033
I5040
I5041
I951
I952
I953
I9581
I9589
I959
N014
N015
N016
N017
N018
N050
N055
N056
N057
N058
N059
N08
N13729 N13731 N13732 N13739 N170
N171
N182
N183
N184
N185
N186
N189
Q202
Q203
Q204
Q205
Q208
Q210
I1310
I2609
I340
I360
I421
I4430
I452
I479
I5020
I5042
N010
N051
N1330
N172
N250
Q211
I1311
I2690
I341
I361
I422
I4439
I453
I480
I5021
I5043
N011
N052
N1339
N178
N2589
Q212
I132
I2692
I342
I362
I424
I444
I454
I481
I5022
I509
N012
N053
N13721
N179
Q200
Q213
I150
I2699
I348
I368
I425
I445
I455
I482
I5023
I950
N013
N054
N13722
N181
Q201
R001
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
T800XXA, T800XXA, T81718A,
T81718A,
T8172XA,
12690
I2699
12690
12699
12690
ICD-10 Special Bulletin, No. 8
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T8172XA,
12699
T82817A,
12690
T82817A,
12699
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Comprehensive Care Program (CCP) Providers
Combination Diagnosis Codes (Must be submitted in pairs)
T82818A,
T82818A,
12690
12699
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Prior authorization for manual and automated blood pressure devices is required for all diagnoses not listed in the
above tables.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.5.4.1.1,
“Manual and Automated Blood Pressure Devices,” and the Durable medical Equipment, Medical Supplies,
and Nutritional Products Handbook, subsection 2.2.6.1, “Prior Authorization,” for additional information.
Cranial Molding Orthosis – CCP
The most appropriate ICD-10-CM diagnosis code that indicates synostotic plagiocephaly must be submitted with
the cranial molding orthosis procedure code S1040.
Procedure code S1040 may be reimbursed for clients who are 3 through 18 months of age with synostotic plagiocephaly.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.10.3, “Cranial
Molding Orthosis,” for additional information.
Nutritional Products - CCP
Nutritional products may be reimbursed without prior authorization when they are submitted with the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C880
C965
C966
D472
D800
D801
D802
D803
D804
D805
D806
D807
D808
D809
D810
D811
D812
D814
D816
D817
D8189
D819
D820
D821
D822
D823
D824
D828
D829
D830
D831
D832
D838
D839
D840
D841
D848
D849
D890
D891
D893
D8982
D8989
D899
E201
E670
E671
E672
E673
E678
E68
E700
E701
E7020
E7021
E7029
E7030
E70310
E70311
E70318
E70319
E70320
E70321
E70328
E70329
E70330
E70331
E70338
E70339
E7039
E7040
E7041
E7049
E705
E708
E709
E710
E71110
E71111
E71118
E71120
E71121
E71128
E7119
E712
E7130
E71310
E71311
E71312
E71313
E71314
E71318
E7132
E7139
E7140
E7141
E7142
E7143
E71440
E71448
E7150
E71510
E71511
E71518
E71520
E71521
E71522
E71528
E71529
E7153
E71540
E71541
E71542
E71548
E7200
E7201
E7202
E7203
E7204
E7209
E7210
E7211
E7212
E7219
E7220
E7221
E7222
E7223
E7229
E723
E724
E7250
E7251
E7252
E7253
E7259
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Comprehensive Care Program (CCP) Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E728
E729
E730
E738
E739
E7403
E7404
E7409
E7410
E7411
E7421
E7429
E7431
E7439
E744
E7509
E7510
E7511
E7519
E7521
E75241
E75242
E75243
E75248
E75249
E755
E756
E7601
E7602
E7603
E76219
E7622
E7629
E763
E768
E778
E779
E780
E781
E782
E786
E7870
E7879
E7881
E7889
E798
E799
E800
E801
E8020
E804
E805
E806
E807
E8300
E8319
E8330
E8331
E8332
E8339
E8349
E8350
E8351
E8352
E8359
E840
E8411
E8419
E848
E849
E853
E854
E858
E859
E860
E871
E872
E873
E874
E875
E878
E8801
E8809
E881
E882
E8849
E8881
E8889
E889
H49811
M10011
M10012
M10019
M10021
M10022
M10039
M10041
M10042
M10049
M10051
M10062
M10069
M10071
M10072
M10079
M10112
M10121
M10122
M10131
M10132
M10152
M10161
M10162
M10171
M10172
M10222
M10231
M10232
M10241
M10242
M10262
M10271
M10272
M1030
M10311
M10322
M10329
M10331
M10332
M10339
M10351
M10352
M10359
M10361
M10362
M10379
M1038
M1039
M1040
M10411
M10422
M10429
M10431
M10432
M10439
M10451
M10452
M10459
M10461
M10462
M10479
M1048
M1049
M109
M1A00X0
M1A0120
M1A0121
M1A0190
M1A0191
M1A0210
M1A0290
M1A0291
M1A0310
M1A0311
M1A0320
M1A0410
M1A0411
M1A0420
M1A0421
M1A0490
M1A0520
M1A0521
M1A0590
M1A0591
M1A0610
M1A0690
M1A0691
M1A0710
M1A0711
M1A0720
M1A08X0
M1A08X1
M1A09X0
M1A09X1
M1A20X0
M1A2120
M1A2121
M1A2190
M1A2191
M1A2210
M1A2290
M1A2291
M1A2310
M1A2311
M1A2320
M1A2410
M1A2411
M1A2420
M1A2421
M1A2490
M1A2520
M1A2521
M1A2590
M1A2591
M1A2610
M1A2691
M1A2710
M1A2711
M1A2720
M1A2721
M1A28X1
M1A29X0
M1A29X1
M1A30X0
M1A30X1
M1A3121
M1A3190
M1A3191
M1A3210
M1A3211
ICD-10 Special Bulletin, No. 8
113
E7400
E7412
E748
E7522
E7529
E761
E769
E783
E789
E8021
E8301
E8340
E8381
E850
E861
E876
E8840
H49812
M10029
M10052
M1008
M10141
M10211
M10251
M10312
M10341
M10369
M10412
M10441
M10469
M1A00X1
M1A0211
M1A0321
M1A0491
M1A0611
M1A0721
M1A20X1
M1A2211
M1A2321
M1A2491
M1A2620
M1A2790
M1A3110
M1A3220
E7401
E7419
E749
E7523
E753
E76210
E770
E784
E791
E8029
E8309
E8341
E8389
E851
E869
E8770
E8841
H49813
M10031
M10059
M1009
M10142
M10212
M10252
M10319
M10342
M10371
M10419
M10442
M10471
M1A0110
M1A0220
M1A0390
M1A0510
M1A0620
M1A0790
M1A2110
M1A2220
M1A2390
M1A2510
M1A2621
M1A2791
M1A3111
M1A3221
E7402
E7420
E7500
E75240
E754
E76211
E771
E785
E792
E803
E8310
E8342
E839
E852
E870
E8779
E8842
M1000
M10032
M10061
M10111
M10151
M10221
M10261
M10321
M10349
M10372
M10421
M10449
M10472
M1A0111
M1A0221
M1A0391
M1A0511
M1A0621
M1A0791
M1A2111
M1A2221
M1A2391
M1A2511
M1A2690
M1A28X0
M1A3120
M1A3290
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Comprehensive Care Program (CCP) Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M1A3291
M1A3310
M1A3311
M1A3320
M1A3321
M1A3411
M1A3420
M1A3421
M1A3490
M1A3491
M1A3521
M1A3590
M1A3591
M1A3610
M1A3611
M1A3691
M1A3710
M1A3711
M1A3720
M1A3721
M1A38X1
M1A39X0
M1A39X1
M1A40X0
M1A40X1
M1A4121
M1A4190
M1A4191
M1A4210
M1A4211
M1A4291
M1A4310
M1A4311
M1A4320
M1A4321
M1A4411
M1A4420
M1A4421
M1A4490
M1A4491
M1A4521
M1A4590
M1A4591
M1A4610
M1A4611
M1A4691
M1A4710
M1A4711
M1A4720
M1A4721
M1A48X1
M1A49X0
M1A49X1
M1A9XX0 M1A9XX1
Z87738
Z931
Z934
M1A3390
M1A3510
M1A3620
M1A3790
M1A4110
M1A4220
M1A4390
M1A4510
M1A4620
M1A4790
M359
M1A3391
M1A3511
M1A3621
M1A3791
M1A4111
M1A4221
M1A4391
M1A4511
M1A4621
M1A4791
N200
M1A3410
M1A3520
M1A3690
M1A38X0
M1A4120
M1A4290
M1A4410
M1A4520
M1A4690
M1A48X0
Z431
Prior authorization is required through CCP for nutritional products that are provided for clients who do not meet
the requirements as outlined in the Texas Medicaid Provider Procedures Manual. A request for prior authorization
must include the client’s diagnosis or condition identified by the most appropriate ICD-10-CM diagnosis code.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.5.11, “Nutritional Products,” for additional information.
Respiratory Care Equipment–CCP
Rental of a cardiorespiratory (apnea) monitor with recording feature (procedure code E0619) may be considered for
use in the home for two months without prior authorization for infants birth through four months of age if one of
the following ICD-10-CM diagnosis codes is indicated on the claim:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G9009
I440
I441
I442
I4430
I4439
I471
I479
I498
K219
P228
P270
P271
P278
P282
P283
P284
P285
P2889
P2911
P2912
Q246
R000
R0681
Z8489
Diagnosis code 1498 includes atrial tachycardia (supraventricular tachycardia [SVT], atrioventricular nodal
reentrant tachycardia [AV nodal re-entry], nodal, and sinoauricular) and bradycardia (nodal, sinoatrial).
For diagnosis code Z8489, providers must submit additional documentation to support medical necessity.
Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.6, “Durable
Medical Equipment (DME) Supplier (CCP),” for additional information.
ICD-10 Special Bulletin, No. 8
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2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
Texas Medicaid Forms
TEXAS MEDICAID FORMS
Prior Authorization Forms
The following Texas Medicaid prior authorization forms have been revised to accommodate the changes associated with ICD-10. These forms must be used to request prior authorizations for services to be rendered on or after
October 1, 2015.
PA Forms
CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services
CCP Prior Authorization Request Form
CCP Prior Authorization Request Form Instructions
Home Health Plan of Care (POC)
Home Health Plan of Care (POC) Instructions
Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form
Intrathecal Baclofen or Morphine Pump
Obstetric Ultrasound Prior Authorization Request Instructions
Private Duty Nursing Prior Authorization Forms
Request for CCP Outpatient Therapy
Request for Outpatient Physical, Occupational, or Speech Therapy (PT, OT, ST) Special Medical Prior
Authorization Form Instructions
Special Medical Prior Authorization (SMPA) Request Form
The following are examples of claim forms submitted with ICD-10-CM diagnosis codes and dates of service on or
after October 1, 2015:
• CMS-1500 claim form example and ICD-10 relevant instructions
• UB-04 claim form example and ICD-10 relevant instructions
• Family Planning 2017 claim form example and ICD-10 relevant instructions
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CPT only copyright 2014 American Medical Association. All rights reserved.
DSHS Family Planning Program Providers/Texas Women’s Health Program (WHP) Providers
DSHS FAMILY PLANNING PROGRAM PROVIDERS
DSHS Family Planning Program Benefit Changes
The following DSHS Family Planning Program (formerly family planning Titles V, X, and XX) benefit changes have
been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.
For questions, call the TMHP Contact Center at 1-800-925-9126.
Diagnosis Codes for Family Planning
The family planning annual examination may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z30011
Z30013 Z30014
Z30018
Z3002
Z3009
Z302
Z3040
Z3041
Z3042
Z30430 Z30431 Z30432 Z30433 Z3049
Z308
Z309
Z9851
Z9852
Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health Services Handbook,
subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization,” for additional information.
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TEXAS WOMEN’S HEALTH PROGRAM (WHP) PROVIDERS
TWHP Benefit Changes
The following TWHP benefit changes have been made to support the 2015 ICD-10 updates and are effective for
dates of service on or after October 1, 2015.
For questions, call the TMHP Contact Center at 1-800-925-9126.
Diagnosis Codes for Family Planning
For TWHP family planning claims to process correctly, providers must use one of the following diagnosis codes in
conjunction with all TWHP family planning procedures and services:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A5400
A5402
A5409
A541
Z30011
Z30018
Z3002
Z3009
Z302
Z3040
Z3041
Z3042
Z30430 Z30431 Z30432 Z30433 Z3049
Z308
Z309
Z9851
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Medical Transportation Program (MTP) Providers/Inpatient Hospital ICD-10-PCS Surgical Procedure Code
MEDICAL TRANSPORTATION PROGRAM (MTP) PROVIDERS
MTP Benefit Changes
The following MTP benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates
of service on or after October 1, 2015.
MTP providers must use the following diagnosis code when submitting claims:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R69
R99
R69 Illness, unspecified; R99 Ill-defined and unknown cause of mortality
Refer to: The Texas Medicaid Provider Procedures Manual, Medical Transportation Program Handbook, subsection
6.3, “Important Codes for All MTP Providers.”
For questions, call the TMHP Contact Center at 1-800-925-9126.
INPATIENT HOSPITAL ICD-10-PCS SURGICAL PROCEDURE CODE UPDATES
ICD-10 and DRG Code Changes for Inpatient Hospital Providers
This section includes information about the surgical procedure and DRG code changes related to ICD-10-PCS for
inpatient hospital providers. These changes are effective for dates of discharge on or after October 1, 2015.
These changes apply to Texas Medicaid fee-for-service and Medicaid managed care claims and authorization
requests that are submitted to TMHP for processing. If the client’s claims are submitted to and processed by
a managed care organization (MCO), the provider must contact the client’s MCO for benefit, limitation, and
processing information.
Note: This section does not contain a complete list of ICD-10-PCS surgical procedure codes. The complete list of 2015
ICD-10 codes including descriptions can be found in the 2015 ICD-10 coding manual available through CMS.
Providers may refer to the TMHP website for the complete list of DRG relative weights, mean lengths of stay, and
day thresholds for effective for dates of admission of or after October 1, 2015. The information is available in the
“Software, Fee Schedules, Reference Codes: section under “Acute Care Reference Codes.”
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CSHCN Services Program Providers
CSHCN SERVICES PROGRAM PROVIDERS
CSHCN Services Program Benefit Changes
The following CSHCN Services Program benefit changes have been made to support the 2015 ICD-10 updates and
are effective for dates of service on or after October 1, 2015.
For questions, call the TMHP-CSHCN Contact Center at 1-800-568-2413.
Ambulance Services
Effective for dates of service on or after October 1, 2015, the following condition codes must be used to identify
emergency medical conditions for ambulance transports:
Ambulance Emergency Condition Codes
B9689
B999
E869
F068
F10929
F19939
F29
G4489
G8929
H579
I469
I499
J9600
J984
M549
O2690
R002
R0602
R0689
R079
R092
R0989
R100
R109
R238
R4182
R4189
R4589
R509
R52
R55
R569
R58
R6889
R7309
S0590XA
T07
T148
T17300A
T300
T50904A
T59891A
T5994XA
T672XXA
T675XXA
T68XXXA T699XXA
T7500XA
T751XXA
T754XXA T782XXA T7840XA
T8189XA
T82519A
T887XXA Y710
Y828
Z209
Z7401
Z779
Z9181
Z9981
Z9989
An emergency transport may be reimbursed by the CSHCN Services Program when it is submitted with modifier
ET and one or more of the emergency medical condition codes in the above table.
The requesting facility or physician must include with the claim, documentation that describes the client’s condition
which necessitated the ambulance transport. Medicaid recognizes limitations of usual ambulance personnel for
establishing a diagnosis, and recognizes that diagnosis coding of a client’s condition using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) when reporting ambulance transport services
may be less specific than for services reported by other professional providers.
Providers who submit ICD-10-CM diagnosis codes should choose the code that best describes the client’s condition
at the time of transport. Diagnoses that are “rule out” or “suspected” diagnoses should not be reported using
specific ICD-10-CM diagnosis codes. In such instances where a diagnosis is not confirmed, it is more correct to use
a symptom, finding, or injury diagnosis code.
Refer to:The CSHCN Services Program Provider Manual, Section 9.3 “Emergency Ambulance Transports,” for
additional information.
Behavioral Health
Procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90847, and 90853 may be reimbursed when they are
submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F0390
F0391
G3184
R41841
Refer to:The CSHCN Services Program Provider Manual, section 29.2.8.1 “Treatment for Alzheimer’s and
Dementia,” for additional information.
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CSHCN Services Program Providers
Blood Pressure Devices
Blood pressure devices, manual (procedure code A4660) and automated (procedure code A4670) may be
reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I10
I110
I119
I120
I129
I130
I151
I152
I158
I159
I2541
I2582
I2692
I2699
I270
I271
I2781
I2782
I342
I348
I349
I350
I351
I352
I362
I368
I369
I370
I371
I372
I421
I422
I423
I424
I425
I428
I4439
I444
I445
I4460
I4469
I447
I454
I455
I456
I4589
I459
I471
I482
I483
I484
I4891
I4892
I495
I5023
I5030
I5031
I5032
I5033
I5040
I950
I951
I952
I953
I9581
I9589
N003
N004
N005
N006
N007
N008
N013
N014
N015
N016
N017
N018
N033
N034
N035
N036
N037
N038
N043
N044
N045
N046
N047
N048
N053
N054
N055
N056
N057
N058
N172
N178
N179
N181
N182
N183
N19
N250
N251
N2581
N2589
N259
I1310
I2601
I2789
I358
I378
I440
I450
I472
I501
I5041
I959
N009
N019
N039
N049
N059
N184
N269
I1311
I2602
I279
I359
I379
I441
I4510
I479
I5020
I5042
N000
N010
N030
N040
N050
N08
N185
N270
I132
I2609
I340
I360
I38
I442
I4519
I480
I5021
I5043
N001
N011
N031
N041
N051
N170
N186
N271
I150
I2690
I341
I361
I39
I4430
I452
I481
I5022
I509
N002
N012
N032
N042
N052
N171
N189
R001
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
T800XXA, T800XXA, T81718A,
T81718A,
T8172XA,
I2690
I2699
I2690
I2699
I2690
T82818A,
T82818A,
I2690
I2699
T8172XA,
I2699
T82817A,
I2690
T82817A,
I2699
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Prior authorization is required for all diagnosis codes not listed in the above tables. Providers must maintain
documentation to support medical necessity in the medical record.
Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The CSHCN Services Program Provider Manual, subsection 11.2.1.1, “Manual and Automated Blood
Pressure Devices,” for additional information.
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CSHCN Services Program Providers
Bone Anchored Hearing Devices
Prior authorization for the bone-anchored hearing aid (BAHA) device may be granted for services rendered to
clients who are five years of age and older with documentation of an appropriate indication that may be causing
hearing impairment. Indications may include, but are not limited to, one of the following:
• Acquired deformities of auricle or pinna
• Congenital anomalies of the external ear canal, middle ear or skull and face bones
• Malignant neoplasm, benign neoplasm or carcinoma of the external ear canal and/or tympanic cavity
• Otosclerosis in clients who cannot undergo stapedectomy
• Severe chronic conductive or sensorineural hearing loss (i.e., otitis media, malformations of the inner ear)
Note: The most appropriate ICD-10 diagnosis code must be included on the claim.
Refer to: The CSHCN Services Program Provider Manual, subsection 20.3.1.1, “Prior Authorization Requirements,”
for additional information.
Botulinum Toxin, Type A and Type B
Procedure codes J0585 (per unit) and J0586 (per 5 units) may be reimbursed when they are submitted with one of
the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G114
G2401
G2402
G241
G243
G244
G245
G248
G249
G35
G360
G370
G371
G372
G373
G374
G375
G378
G379
G512
G513
G514
G518
G800
G801
G802
G803
G804
G808
G809
G8111
G8112
G8113
G8114
G8191
G8192
G8193
G8194
G8220
G8221
G8222
G8250
G8251
G8252
G8253
G8254
G830
G8310
G8311
G8312
G8313
G8314
G8320
G8321
G8322
G8323
G8324
G8330
G8331
G8332
G8333
G8334
G834
G8921
H4901
H4902
H4903
H4911
H4912
H4913
H4921
H4922
H4923
H4931
H4932
H4933
H4941
H4942
H4943
H499
H5000
H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042 H5005
H5006
H5007
H5008
H5010
H50111
H50112 H50121 H50122 H50131 H50132
H50141 H50142 H5015
H5016
H5017
H5018
H5021
H5022
H5030
H50311
H50312 H5032
H50331 H50332 H5034
H5040
H50411 H50412 H5042
H5043
H5050
H5051
H5052
H5053
H5054
H5055
H5060
H50611 H50612 H5069
H50811 H50812 H5089
H510
H5111
H5112
H5121
H5122
H5123
H518
H519
J385
J387
K117
K220
K594
K600
K601
K602
M436
M62838 R252
R532
In addition to the diagnosis codes listed in the above table, procedure code J0585, may be indicated for, but is not
limited to, treatment of the following diagnoses:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
N310
N311
N312
N318
N319
N3281
N3644
Note: The CSHCN Services Program requires a trial of botulinum toxin type A prior to the use of botulinum toxin
type B.
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CSHCN Services Program Providers
Procedure code J0587 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes
or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G243
G8921
Procedure code J0588 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes
as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G243
G245
G8111
G8112
G8113
G8114
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.24.5, “Botulinum Toxin (Type A and
Type B),” for additional information.
Cochlear Implants
Auditory brain implant (ABI) procedure code S2235 may be reimbursed when submitted with the following
ICD-10-CM diagnosis code:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Q8502
Refer to: The CSHCN Services Program Provider Manual, subsection 20.3.2.5, “Limitations,” for additional information.
Cytogenetics Testing
Cytogenetics testing procedure codes may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C8280
C8281
C8282
C8283
C8284
C8285
C8291
C8292
C8293
C8294
C8295
C8296
C8311
C8312
C8313
C8314
C8315
C8316
C8381
C8382
C8383
C8384
C8385
C8386
C8441
C8442
C8443
C8444
C8445
C8446
C8462
C8463
C8464
C8465
C8466
C8467
C8473
C8474
C8475
C8476
C8477
C8478
C8585
C8586
C8587
C8588
C8589
C884
C9102
C9110
C9111
C9112
C9190
C9191
C9200
C9201
C9202
C9210
C9211
C9212
C9231
C9232
C9240
C9241
C9242
C9250
C9262
C9290
C9291
C9292
C92A0
C92A1
C9300
C9301
C9302
C9310
C9311
C9312
C9392
C93Z0
C93Z1
C93Z2
C9400
C9401
C9430
C9431
C9432
C9480
C9481
C9482
C9511
C9512
C9590
C9591
C9592
D45
E343
E83110
E8359
F70
F71
F72
F802
F804
F8089
F810
F812
F8181
F88
F900
F901
F902
F908
H0589
I77819
M2600
M2601
M2602
M2603
M2604
N6482
P293
Q000
Q001
Q002
Q010
ICD-10 Special Bulletin, No. 8
121
C8286
C8297
C8317
C8387
C8447
C8468
C8479
C888
C9192
C9220
C9251
C92A2
C9330
C9402
C9500
D821
F73
F8189
H9325
M2605
Q011
C8287
C8298
C8318
C8388
C8448
C8469
C8581
C9012
C91Z0
C9221
C9252
C92Z0
C9331
C9420
C9501
E230
F78
F819
I77810
M2606
Q012
C8288
C8299
C8319
C8389
C8449
C8471
C8582
C9100
C91Z1
C9222
C9260
C92Z1
C9390
C9421
C9502
E291
F800
F82
I77811
M2607
Q018
C8289
C8310
C8380
C8440
C8461
C8472
C8584
C9101
C91Z2
C9230
C9261
C92Z2
C9391
C9422
C9510
E300
F801
F840
I77812
M2609
Q02
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Q030
Q031
Q038
Q040
Q041
Q042
Q051
Q052
Q054
Q055
Q056
Q057
Q0701
Q0702
Q0703
Q078
Q079
Q100
Q106
Q107
Q110
Q111
Q112
Q113
Q128
Q129
Q130
Q131
Q132
Q133
Q140
Q141
Q142
Q143
Q148
Q150
Q162
Q163
Q164
Q165
Q169
Q170
Q175
Q178
Q179
Q180
Q181
Q182
Q187
Q188
Q189
Q200
Q201
Q202
Q208
Q209
Q210
Q211
Q212
Q213
Q221
Q222
Q223
Q224
Q225
Q228
Q234
Q238
Q240
Q241
Q242
Q243
Q249
Q250
Q251
Q252
Q253
Q254
Q262
Q263
Q265
Q266
Q268
Q269
Q2731
Q2732
Q2733
Q2734
Q274
Q278
Q283
Q288
Q289
Q300
Q301
Q302
Q311
Q312
Q313
Q315
Q318
Q320
Q330
Q331
Q332
Q333
Q334
Q335
Q349
Q351
Q353
Q359
Q360
Q369
Q374
Q375
Q380
Q381
Q382
Q383
Q388
Q391
Q392
Q393
Q394
Q395
Q402
Q408
Q409
Q410
Q411
Q412
Q423
Q428
Q430
Q431
Q432
Q433
Q440
Q441
Q442
Q443
Q444
Q445
Q452
Q453
Q458
Q459
Q5001
Q5002
Q5039
Q504
Q505
Q506
Q510
Q5110
Q517
Q51811
Q51821 Q51828 Q520
Q5210
Q526
Q5270
Q5271
Q5279
Q528
Q529
Q5311
Q5312
Q5320
Q5321
Q5322
Q539
Q544
Q548
Q550
Q551
Q5521
Q5522
Q555
Q5561
Q5562
Q5563
Q5564
Q5569
Q562
Q563
Q564
Q600
Q601
Q603
Q612
Q613
Q614
Q615
Q618
Q619
Q6239
Q624
Q625
Q6261
Q6262
Q6263
Q633
Q638
Q640
Q6410
Q6411
Q6412
Q6433
Q6439
Q644
Q645
Q646
Q6471
Q649
Q6501
Q6502
Q651
Q6531
Q6532
Q660
Q662
Q663
Q664
Q6651
Q6652
Q6689
Q670
Q671
Q672
Q673
Q674
Q680
Q681
Q682
Q683
Q684
Q688
Q7001
Q7002
Q7003
Q7011
Q7012
Q7013
Q7032
Q7033
Q709
Q7101
Q7102
Q7103
Q7132
Q7133
Q7141
Q7142
Q7143
Q7151
Q7163
Q71811 Q71812 Q71813 Q71891 Q71892
ICD-10 Special Bulletin, No. 8
122
Q045
Q058
Q101
Q120
Q134
Q158
Q171
Q183
Q203
Q214
Q230
Q244
Q2572
Q270
Q279
Q303
Q321
Q336
Q370
Q384
Q396
Q419
Q434
Q446
Q501
Q5111
Q522
Q5300
Q540
Q5523
Q558
Q604
Q6211
Q628
Q6419
Q6472
Q654
Q666
Q675
Q690
Q7021
Q7111
Q7152
Q71893
Q046
Q062
Q102
Q121
Q135
Q159
Q172
Q184
Q204
Q218
Q231
Q245
Q259
Q271
Q280
Q308
Q322
Q338
Q371
Q385
Q398
Q420
Q435
Q447
Q502
Q512
Q523
Q5301
Q541
Q5529
Q559
Q606
Q6212
Q630
Q642
Q6473
Q6581
Q667
Q676
Q691
Q7022
Q7112
Q7153
Q7191
Q048
Q064
Q103
Q123
Q1381
Q160
Q173
Q185
Q205
Q219
Q232
Q246
Q260
Q272
Q281
Q309
Q323
Q339
Q372
Q386
Q400
Q421
Q437
Q450
Q5031
Q515
Q524
Q5302
Q542
Q553
Q560
Q6101
Q622
Q631
Q6431
Q6474
Q6582
Q6681
Q677
Q692
Q7023
Q7113
Q7161
Q7192
Q050
Q068
Q104
Q124
Q1389
Q161
Q174
Q186
Q206
Q220
Q233
Q248
Q261
Q2730
Q282
Q310
Q324
Q348
Q373
Q387
Q401
Q422
Q438
Q451
Q5032
Q516
Q525
Q5310
Q543
Q554
Q561
Q6119
Q6231
Q632
Q6432
Q6475
Q6589
Q6682
Q678
Q699
Q7031
Q7131
Q7162
Q7193
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Q7201
Q7202
Q7203
Q7211
Q7212
Q7213
Q7242
Q7243
Q7251
Q7252
Q7253
Q7261
Q7273
Q72811 Q72812 Q72813 Q72891 Q72892
Q730
Q731
Q738
Q740
Q742
Q743
Q752
Q753
Q754
Q755
Q758
Q759
Q76411 Q76412 Q76413 Q76414 Q76415 Q76425
Q765
Q766
Q767
Q768
Q770
Q771
Q777
Q780
Q781
Q782
Q783
Q784
Q792
Q793
Q794
Q7959
Q796
Q798
Q803
Q804
Q808
Q820
Q821
Q822
Q831
Q832
Q833
Q838
Q840
Q841
Q846
Q848
Q849
Q8503
Q851
Q858
Q87418 Q8742
Q8743
Q8901
Q8909
Q891
Q898
Q899
Q900
Q901
Q902
Q909
Q914
Q915
Q916
Q917
Q920
Q921
Q927
Q928
Q930
Q931
Q932
Q933
Q9388
Q9389
Q950
Q952
Q958
Q960
Q968
Q969
Q970
Q971
Q972
Q973
Q985
Q986
Q987
Q988
Q990
Q991
Z31430
Z31438
Z315
Z810
Z8279
Z8489
Q7231
Q7262
Q72893
Q748
Q760
Q76426
Q772
Q788
Q799
Q823
Q842
Q859
Q892
Q910
Q922
Q934
Q961
Q978
Q992
Q7232
Q7263
Q7291
Q749
Q761
Q76427
Q774
Q789
Q800
Q824
Q843
Q870
Q893
Q911
Q925
Q935
Q962
Q980
Q998
Q7233
Q7271
Q7292
Q750
Q762
Q76428
Q775
Q790
Q801
Q828
Q844
Q871
Q894
Q912
Q9261
Q937
Q963
Q981
Q999
Q7241
Q7272
Q7293
Q751
Q763
Q7649
Q776
Q791
Q802
Q830
Q845
Q87410
Q897
Q913
Q9262
Q9381
Q964
Q984
R480
Combination Diagnosis Codes
Combination Diagnosis Codes (Must be submitted in pairs)
Q6501,
Q6502,
Q6532
Q6531
Refer to: The CSHCN Services Program Provider Manual, Section 25 “Laboratory Services,” subsection 25.2.5.1
Cytogenetics Testing for additional information.
Dental Services – Orthodontia
The most appropriate ICD-10-CM diagnosis code that supports medical necessity of the orthodontia service must
be included in the documentation for prior authorization. Indications may include, but are not limited to, one of
the following indications:
• Cleft lip
• Cleft palate
• Congenital anomalies of skull and face bones
• Dentofacial functional abnormalities
• Major anomalies of jaw size
Prior authorization is required for all orthodontic services except for the initial orthodontic visit. Providers must
include in the prior authorization request all the required documentation.
Refer to: The CSHCN Services Program Provider Manual, subsection 14.2.3.2, “Required Documentation,” for the
necessary documentation requirements.
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CSHCN Services Program Providers
Dental – Therapeutic Services
Dental behavior management procedure code D9920 may be considered for prior authorization in addition to
therapeutic procedures when the prior authorization request includes the most appropriate ICD-10-CM diagnosis
code that indicates an intellectual disability described as mild, moderate, severe, profound or unspecified.
Refer to: The CSHCN Services Program Provider Manual, subsection 14.2.5.10, “Dental Behavior Management”
for all supporting documentation requirements.
Diabetic Equipment and Supplies
Diabetic supplies and related testing equipment supplies do not require prior authorization unless otherwise
specified. Prior authorization is required when documentation of medical necessity supports additional quantities
greater than the limitations defined for a client with exceptional needs.
Blood testing and supplies may be reimbursed without prior authorization when they are submitted with one of the
following ICD-10-CM diagnosis codes or combination diagnosis codes:
Diabetic Diagnosis Codes
Diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E0800
E0801
E0810
E0811
E0821
E08319
E08321
E08329
E08331
E08339
E08359
E0836
E0839
E0840
E0841
E0849
E0851
E0859
E08610
E08618
E08628
E08630
E08638
E08641
E08649
E089
E0900
E0901
E0910
E0911
E09311
E09319
E09321
E09329
E09331
E09351
E09359
E0936
E0939
E0940
E0944
E0949
E0951
E0959
E09610
E09622
E09628
E09630
E09638
E09641
E098
E099
E1010
E1011
E1021
E10319
E10321
E10329
E10331
E10339
E10359
E1036
E1039
E1040
E1041
E1049
E1051
E1052
E1059
E10610
E10622
E10628
E10630
E10638
E10641
E108
E109
E1100
E1101
E1121
E11319
E11321
E11329
E11331
E11339
E11359
E1136
E1139
E1140
E1141
E1149
E1151
E1152
E1159
E11610
E11622
E11628
E11630
E11638
E11641
E118
E119
E1300
E1301
E1310
E1329
E13311
E13319
E13321
E13329
E13349
E13351
E13359
E1336
E1339
E1343
E1344
E1349
E1351
E1352
E13621
E13622
E13628
E13638
E13641
E138
E139
P702
ICD-10 Special Bulletin, No. 8
124
E0822
E08341
E0842
E08620
E0865
E0921
E09339
E0941
E09618
E09649
E1022
E10341
E1042
E10618
E10649
E1122
E11341
E1142
E11618
E11649
E1311
E13331
E1340
E1359
E13649
E0829
E08349
E0843
E08621
E0869
E0922
E09341
E0942
E09620
E0965
E1029
E10349
E1043
E10620
E1065
E1129
E11349
E1143
E11620
E1165
E1321
E13339
E1341
E13610
E1365
E08311
E08351
E0844
E08622
E088
E0929
E09349
E0943
E09621
E0969
E10311
E10351
E1044
E10621
E1069
E11311
E11351
E1144
E11621
E1169
E1322
E13341
E1342
E13620
E1369
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Combination Diagnosis Codes (Must be submitted in pairs)
E0800,
E0801,
E0810,
E0821,
E08311,
E0865
E0865
E0865
E0865
E0865
E08331,
E08339,
E08341,
E08349,
E08351,
E0865
E0865
E0865
E0865
E0865
E0840,
E0851,
E0865,
E0865,
E0865,
E0865
E0865
E0841
E0842
E0843
E0865,
E0865,
E0865,
E0865,
E0865,
E0852
E0859
E0869
E088
E0921
E0865,
E0865,
E0865,
E0865,
E0865,
E0940
E0951
E0969
E098
E1365
E0910,
E1010,
E1011,
E1011,
E1011,
E0865
E1065
E10641
E1065
E1311
E1039,
E1040,
E1051,
E1065,
E1065,
E1065
E1065
E1065
E1021
E1022
E1065,
E1065,
E1065,
E1065,
E1065,
E10329
E10331
E10339
E10341
E10359
E1065,
E1065,
E1065,
E1065,
E1065,
E1044
E1049
E10351
E1052
E1059
E1065,
E1065,
E1065,
E1065,
E1065,
E1141
E1142
E1143
E1144
E1149
E1065,
E1065,
E1065,
E1065,
E1065,
E1342
E1343
E1344
E1349
E13610
E1121,
E1121,
E1121,
E1121,
E11311,
E1129
E1321
E1322
E1329
E1165
E1140,
E1151,
E1165,
E1165,
E1321,
E1165
E1165
E1169
E118
E0865
E08319,
E0865
E08359,
E0865
E0865,
E0844
E0865,
E09311
E0865,
E138
E1011,
E13641
E1065,
E1029
E1065,
E1041
E1065,
E10610
E1065,
E11610
E1100,
E1165
E11319,
E1169
E08321,
E0865
E0836,
E0865
E0865,
E0849
E0865,
E09319
E0900,
E0865
E10319,
E1065
E1065,
E10311
E1065,
E1042
E1065,
E1069
E1065,
E1340
E1101,
E1165
E1136,
E1165
E08329,
E0865
E0839,
E0865
E0865,
E0851
E0865,
E0936
E0901,
E0865
E1036,
E1065
E1065,
E10321
E1065,
E1043
E1065,
E108
E1065,
E1341
E1121,
E1122
E1139,
E1165
If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must
be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis
codes in the chosen combination are not submitted.
Non-diabetic Diagnosis Codes
Non-Diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E161
E162
E71111
E71310
E71311
E71312
E71313
E7420
E7421
E7429
E8881
K911
R7309
R81
E71314
E71318
E7132
Blood testing supplies for diagnoses other than those listed in the above diagnosis tables may be considered for prior
authorization with documentation of medical necessity.
Refer to: The Section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional information about submitting claims with combination diagnosis codes.
The CSHCN Services Program Provider Manual, subsection 15.2.1 “Glucose Monitor and Supplies” for
additional information.
ICD-10 Special Bulletin, No. 8
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CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Electroencephalogram (Ambulatory)
Ambulatory electroencephalogram (A/EEG) procedure codes 95950, 95951, 95953, 95956, and 95957 may be
reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
F05
F060
F068
G253
G40001
G40009
G40011
G40019
G40101
G40109
G40111
G40119
G40201
G40209
G40211
G40219
G40301
G40309
G40311
G40319
G40401
G40409
G40411
G40419
G40501
G40509
G40801
G40802
G40803
G40804
G40811
G40812
G40813
G40814
G4089
G40901
G40909
G40911
G40919
G40A11
G40A19
G40B01
G40B09
G40B11
G40B19
G912
G9381
G9389
P912
R561
R569
Z85020
Z85030
Z85040
Z85060
Z85110
Z85230
Z85520
Z85821
Z85841
Z85848
Z86011
Z8669
Z87728
Z87798
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.16.2, “Ambulatory Electroencephalogram,” for additional information.
Evoked Response Tests
Electromyography (EMG) and nerve conduction study (NCS) procedures may be reimbursed when submitted with
one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C701
C720
C721
E0842
E0942
E1041
E1042
E10610
E1141
E1142
E1144
E11610
E1342
E5111
E5112
E512
E518
E519
E560
E568
E786
E851
E852
E853
E858
E859
G120
G121
G1221
G1222
G1229
G128
G129
G130
G243
G2589
G26
G320
G360
G370
G375
G501
G510
G511
G512
G513
G514
G518
G519
G522
G523
G527
G528
G540
G541
G542
G543
G544
G545
G548
G549
G5601
G5602
G5611
G5612
G5621
G5622
G5631
G5632
G5641
G5642
G5681
G5682
G5691
G5692
G5701
G5702
G5711
G5712
G5721
G5722
G5731
G5732
G5741
G5742
G5751
G5752
G5761
G5762
G5771
G5772
G5781
G5782
G5791
G5792
G587
G588
G589
G59
G600
G601
G602
G603
G608
G609
G610
G6181
G6189
G619
G620
G621
G622
G6281
G6282
G629
G63
G650
G651
G652
G7000
G7001
G701
G702
G7081
G7089
G709
G710
G7111
G7112
G7113
G7114
G7119
G712
G713
G718
G719
G721
G722
G723
G7241
G7249
G7281
G7289
G729
G731
G733
G737
G834
G8381
G8382
G8383
G8384
G8389
G839
G9009
G902
G904
G9050
G90511
G90512
G90513
G90519
G90521
G90522
G90523
G90529
G9059
G909
G950
G9511
G9519
G9520
G9529
G9581
G9589
G959
G990
G992
I776
I951
J3800
J3801
J3802
K5902
K5909
K592
K594
K624
K6289
M05411
M05412
M05421
ICD-10 Special Bulletin, No. 8
126
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M05422
M05431
M05432
M05441
M05442
M05462
M05471
M05472
M0549
M05511
M05531
M05532
M05541
M05542
M05551
M05571
M05572
M0559
M05711
M05712
M05732
M05741
M05742
M05751
M05752
M05771
M05772
M05779
M0579
M05811
M05831
M05832
M05841
M05842
M05851
M05871
M05872
M0589
M06011
M06012
M06032
M06041
M06042
M06051
M06052
M06072
M0608
M0609
M06811
M06812
M06832
M06841
M06842
M06852
M06861
M0688
M0689
M069
M21271
M21272
M21512
M216X1
M216X2
M21831
M21832
M3210
M3211
M3212
M3213
M3214
M329
M3300
M3301
M3302
M3309
M3319
M3320
M3321
M3322
M3329
M3399
M340
M341
M342
M3481
M358
M360
M4321
M4322
M4323
M4327
M4328
M436
M438X9
M4644
M4711
M4712
M4713
M4714
M4715
M4721
M4722
M4723
M4724
M4725
M47811
M47812
M47813
M47814
M47815
M47891
M47892
M47893
M47894
M47895
M4801
M4802
M4803
M4804
M4805
M5000
M5001
M5002
M5003
M5011
M5021
M5022
M5023
M5030
M5031
M5081
M5082
M5083
M5091
M5092
M5106
M5107
M5124
M5125
M5126
M5136
M5137
M5184
M5185
M5186
M5412
M5413
M5414
M5415
M5416
M545
M546
M5489
M60011
M60012
M60032
M60041
M60042
M60044
M60045
M60061
M60062
M60070
M60071
M60073
M6008
M6009
M60111
M60112
M60121
M60141
M60142
M60151
M60152
M60161
M6018
M6019
M609
M6250
M62511
M62522
M62529
M62531
M62532
M62539
M62551
M62552
M62559
M62561
M62562
M62579
M6258
M6259
M6281
M629
M79602
M79604
M79605
M79621
M79622
M79642
M79651
M79652
M79661
M79662
M961
N393
N3941
N3942
N3943
N39490
N39498
N94819
R150
R151
R201
R202
R203
R208
R209
ICD-10 Special Bulletin, No. 8
127
M05451
M05512
M05552
M05721
M05761
M05812
M05852
M06021
M06061
M06821
M06862
M21331
M21931
M3215
M3310
M3390
M3482
M4324
M4645
M4716
M4726
M47816
M47896
M4806
M5012
M5032
M5093
M5127
M5187
M5417
M60021
M60046
M60074
M60122
M60162
M62512
M62541
M62569
M791
M79631
M79671
N3944
R152
R260
M05452
M05521
M05561
M05722
M05762
M05821
M05861
M06022
M06062
M06822
M06871
M21332
M21932
M3219
M3311
M3391
M3483
M4325
M4646
M4717
M4727
M47817
M47897
M4807
M5013
M5033
M5104
M5134
M5410
M5431
M60022
M60051
M60076
M60131
M60171
M62519
M62542
M62571
M792
M79632
M79672
N3945
R159
R261
M05461
M05522
M05562
M05731
M05769
M05822
M05862
M06031
M06071
M06831
M06872
M21511
M320
M328
M3312
M3392
M3489
M4326
M4647
M4718
M4728
M47818
M47898
M4808
M5020
M5080
M5105
M5135
M5411
M5432
M60031
M60052
M60077
M60132
M60172
M62521
M62549
M62572
M79601
M79641
M797
N3946
R200
R2681
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
R2689
R269
R290
R295
R32
R4781
R4789
R498
R6884
S14101A
S14102D
S14102S
S14103A
S14103D
S14103S
S14105A
S14105D
S14105S
S14106A
S14106D
S14107S
S14108A
S14108D
S14108S
S14109A
S14111D
S14111S
S14112A
S14112D
S14112S
S14114A
S14114D
S14114S
S14115A
S14115D
S14116S
S14117A
S14117D
S14117S
S14118A
S14121D
S14121S
S14122A
S14122D
S14122S
S14124A
S14124D
S14124S
S14125A
S14125D
S14126S
S14127A
S14127D
S14127S
S14128A
S14131D
S14131S
S14132A
S14132D
S14132S
S14134A
S14134D
S14134S
S14135A
S14135D
S14136S
S14137A
S14137D
S14137S
S14138A
S14141D
S14141S
S14142A
S14142D
S14142S
S14144A
S14144D
S14144S
S14145A
S14145D
S14146S
S14147A
S14147D
S14147S
S14148A
S14151D
S14151S
S14152A
S14152D
S14152S
S14154A
S14154D
S14154S
S14155A
S14155D
S14156S
S14157A
S14157D
S14157S
S14158A
S142XXD
S142XXS
S143XXA
S143XXD
S143XXS
S145XXA
S145XXD
S145XXS
S148XXA
S148XXD
S149XXS
S24101A
S24101D
S24101S
S24102A
S24103D
S24103S
S24104A
S24104D
S24104S
S24111A
S24111D
S24111S
S24112A
S24112D
S24113S
S24114A
S24114D
S24114S
S24131A
S24132D
S24132S
S24133A
S24133D
S24133S
S24141A
S24141D
S24141S
S24142A
S24142D
S24143S
S24144A
S24144D
S24144S
S24151A
S24152D
S24152S
S24153A
S24153D
S24153S
S242XXA
S242XXD
S242XXS
S243XXA
S243XXD
S244XXS
S248XXA
S248XXD
S248XXS
S249XXA
S34111D
S34111S
S34112A
S34112D
S34112S
S34114A
S34114D
S34114S
S34115A
S34115D
S34121S
S34122A
S34122D
S34122S
S34123A
S34124D
S34124S
S34125A
S34125D
S34125S
S34132A
S34132D
S34132S
S34139A
S34139D
S3421XS
S3422XA
S3422XD
S3422XS
S343XXA
S344XXD
S344XXS
S345XXA
S345XXD
S345XXS
S4401XA
S4401XD
S4401XS
S4402XA
S4402XD
S4410XS
S4411XA
S4411XD
S4411XS
S4412XA
S4420XD
S4420XS
S4421XA
S4421XD
S4421XS
S4430XA
S4430XD
S4430XS
S4431XA
S4431XD
S4432XS
S4440XA
S4440XD
S4440XS
S4441XA
ICD-10 Special Bulletin, No. 8
128
R3914
S14101D
S14104A
S14106S
S14109D
S14113A
S14115S
S14118D
S14123A
S14125S
S14128D
S14133A
S14135S
S14138D
S14143A
S14145S
S14148D
S14153A
S14155S
S14158D
S144XXA
S148XXS
S24102D
S24109A
S24112S
S24131D
S24134A
S24142S
S24151D
S24154A
S243XXS
S34109A
S34113A
S34115S
S34123D
S34131A
S34139S
S343XXD
S4400XA
S4402XS
S4412XD
S4422XA
S4431XS
S4441XD
R4702
S14101S
S14104D
S14107A
S14109S
S14113D
S14116A
S14118S
S14123D
S14126A
S14128S
S14133D
S14136A
S14138S
S14143D
S14146A
S14148S
S14153D
S14156A
S14158S
S144XXD
S149XXA
S24102S
S24109D
S24113A
S24131S
S24134D
S24143A
S24151S
S24154D
S244XXA
S34109D
S34113D
S34121A
S34123S
S34131D
S3421XA
S343XXS
S4400XD
S4410XA
S4412XS
S4422XD
S4432XA
S4441XS
R471
S14102A
S14104S
S14107D
S14111A
S14113S
S14116D
S14121A
S14123S
S14126D
S14131A
S14133S
S14136D
S14141A
S14143S
S14146D
S14151A
S14153S
S14156D
S142XXA
S144XXS
S149XXD
S24103A
S24109S
S24113D
S24132A
S24134S
S24143D
S24152A
S24154S
S244XXD
S34111A
S34113S
S34121D
S34124A
S34131S
S3421XD
S344XXA
S4400XS
S4410XD
S4420XA
S4422XS
S4432XD
S4442XA
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CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
S4442XD
S4442XS
S4450XA
S4450XD
S4450XS
S4452XA
S4452XD
S4452XS
S448X1A
S448X1D
S448X2S
S448X9A
S448X9D
S448X9S
S4491XA
S4492XD
S4492XS
S5400XA
S5400XD
S5400XS
S5402XA
S5402XD
S5402XS
S5410XA
S5410XD
S5411XS
S5412XA
S5412XD
S5412XS
S5420XA
S5421XD
S5421XS
S5422XA
S5422XD
S5422XS
S5431XA
S5431XD
S5431XS
S5432XA
S5432XD
S5490XS
S5491XA
S5491XD
S5491XS
S5492XA
S6400XD
S6400XS
S6401XA
S6401XD
S6401XS
S6410XA
S6410XD
S6410XS
S6411XA
S6411XD
S6412XS
S6420XA
S6420XD
S6420XS
S6421XA
S6422XD
S6422XS
S6430XA
S6430XD
S6430XS
S6432XA
S6432XD
S6432XS
S64490A
S64490D
S64491S
S64492A
S64492D
S64492S
S64493A
S64494D
S64494S
S64495A
S64495D
S64495S
S64497A
S64497D
S64497S
S64498A
S64498D
S648X1S
S648X2A
S648X2D
S648X2S
S648X9A
S6490XD
S6490XS
S6491XA
S6491XD
S6491XS
S7401XS
S7402XA
S7402XD
S7402XS
S7411XA
S7412XD
S7412XS
S7421XA
S7421XD
S7421XS
S748X1A
S748X1D
S748X1S
S748X2A
S748X2D
S7491XS
S7492XA
S7492XD
S7492XS
S8401XA
S8402XD
S8402XS
S8411XA
S8411XD
S8411XS
S8421XA
S8421XD
S8421XS
S8422XA
S8422XD
S84801S
S84802A
S84802D
S84802S
S8491XA
S8492XD
S8492XS
S9421XA
S9421XD
S9421XS
S9431XA
S9431XD
S9431XS
S9432XA
S9432XD
S948X1S
S948X2A
S948X2D
S948X2S
S948X9D
S9491XS
S9492XA
S9492XD
S9492XS
S4451XA
S448X1S
S4491XD
S5401XA
S5410XS
S5420XD
S5430XA
S5432XS
S5492XD
S6402XA
S6411XS
S6421XD
S6431XA
S64490S
S64493D
S64496A
S64498S
S648X9D
S6492XA
S7411XD
S7422XA
S748X2S
S8401XD
S8412XA
S8422XS
S8491XD
S9422XA
S9432XS
S948X9S
S4451XD
S448X2A
S4491XS
S5401XD
S5411XA
S5420XS
S5430XD
S5490XA
S5492XS
S6402XD
S6412XA
S6421XS
S6431XD
S64491A
S64493S
S64496D
S648X1A
S648X9S
S7401XA
S7411XS
S7422XD
S7491XA
S8401XS
S8412XD
S84801A
S8491XS
S9422XD
S948X1A
S9490XD
S4451XS
S448X2D
S4492XA
S5401XS
S5411XD
S5421XA
S5430XS
S5490XD
S6400XA
S6402XS
S6412XD
S6422XA
S6431XS
S64491D
S64494A
S64496S
S648X1D
S6490XA
S7401XD
S7412XA
S7422XS
S7491XD
S8402XA
S8412XS
S84801D
S8492XA
S9422XS
S948X1D
S9491XA
Prior authorization is required for any diagnosis other than those listed in the above table or when the number of
NCS procedures performed during an evaluation exceeds the allowed maximum number of studies.
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.18.2, “Electromyography and Nerve
Conduction Studies,” for additional information.
Expendable Medical Supplies
Diapers, briefs, pull-ups, or liners in any combination may be covered for clients who are 4 years of age and older
who are incontinent as a direct result of a medical condition.
Diapers, briefs, pull-ups, or liners do not require prior authorization up to a combined total of 240 items per month
when the most appropriate procedure code is submitted with an applicable diagnosis code. Click here to view the
list of applicable diagnosis codes.
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Hearing Services
Procedure code 92568 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D333
G510
G511
G518
G519
H8001
H8002
H8003
H8011
H8012
H8013
H8021
H8022
H8023
H8081
H8082
H8083
H8091
H8092
H8093
H8101
H8102
H8103
H8111
H8112
H8113
H8121
H8122
H8123
H81311
H81312
H81313
H81319
H81391
H81392
H81393
H8141
H8142
H8143
H818X1
H818X2
H818X3
H8191
H8192
H8193
H8301
H8302
H8303
H8311
H8312
H8313
H832X1
H832X2
H832X3
H838X1
H838X2
H838X3
H838X9
H8391
H8392
H8393
H900
H9011
H9012
H902
H903
H9041
H9042
H905
H906
H9071
H9072
H908
H9101
H9102
H9103
H9109
H9121
H9122
H9123
H918X1
H918X2
H918X3
H9191
H9192
H9193
H9311
H9312
H9313
H93211
H93212
H93213
H93221
H93222
H93223
H93231
H93232
H93233
H93241
H93242
H93243
H93291
H93292
H93293
H933X1
H933X2
H933X3
H933X9
Q179
R42
Refer to: The CSHCN Services Program Provider Manual, subsection 20.2.3.5, “Limitations,” for additional information.
Helicobacter pylori Testing
Serology testing (procedure codes 83009, 86677, and 87339), breath testing (procedure codes 78267, 78268, 83013,
and 83014), and stool testing (procedure code 87338) may be reimbursed when the most appropriate procedure
code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C160
C161
C162
C163
C164
C165
C166
C168
K250
K251
K252
K253
K254
K255
K256
K257
K260
K261
K262
K263
K264
K265
K266
K267
K270
K271
K272
K273
K274
K275
K276
K277
K280
K281
K282
K283
K284
K285
K286
K287
K2900
K2901
K2931
K2940
K2941
K2960
K2961
K2980
K2981
K2990
Additionally, H. pylori breath and stool testing procedure codes 78267, 78268, 83013, 83014, and 87338 may be
reimbursed when they are submitted with the following ICD-10-CM diagnosis code:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B9681
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.26.8, “Helicobacter pylori (H. pylori),”
and subsection 25.2.8, “Helicobacter pylori (H.pylori),” for additional information.
Injection-Clofarabine
Prior authorization of clofarabine (Clorar) injection is required. Documentation of the following must be submitted
with the prior authorization request:
• Refractory or relapsed acute lymphoblastic leukemia (C9100 or C9102)
• At least two prior failed regimens
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CSHCN Services Program Providers
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.24.3, “Injection Procedure Codes,” for
additional information.
Mastectomy and Reconstructive/Cosmetic Procedures
Mastectomy and breast reconstruction procedure codes may be reimbursed when they are submitted with one of
the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C50011
C50012
C50021
C50022
C50111
C50112
C50121
C50122
C50211
C50212
C50221
C50222
C50311
C50312
C50321
C50322
C50411
C50412
C50421
C50422
C50511
C50512
C50521
C50522
C50611
C50612
C50621
C50622
C50811
C50812
C50821
C50822
C50921
C50922
C7981
D0501
D0502
D0511
D0512
D0581
D0582
The following additional diagnosis codes are benefits for simple, subcutaneous, radical, and modified radical
mastectomies and for all breast reconstruction procedures:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
Z1501
Z803
Z853
Z9011
Z9012
Z9013
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.36.12, “Mastectomy and Related
Services,” for additional information.
Medical Foods
The Children with Special Health Care Needs (CSHCN) Services Program may cover medical foods for clients
who have inborn errors of metabolism that prohibit them from eating a regular diet.
The following ICD10-CM diagnosis codes may be used for inborn metabolic disorders:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E700
E701
E7020
E7021
E7029
E7030
E70329
E70330
E70339
E7039
E705
E708
E709
E710
E7119
E7201
E7204
E7211
E7212
E7219
E7221
E7222
E7223
E7229
H3120
E70331
E7202
E723
E70338
E7203
E724
Refer to: The CSHCN Services Program Provider Manual, subsection 26.3.2.1, “Prior Authorization Requirements,”
for additional information.
Medical Nutritional Products
Providers must include the most appropriate ICD-10-CM diagnosis code on claims for medical nutritional
products. Prior authorization is required every six months for medical nutritional products if the client has one of
the following conditions that is expected to be permanent or of indefinite duration:
• Anatomical, physiological, or motility disorder of the gastrointestinal tract
• Anatomical abnormality or disease of digestive system
• Malignancy
• Infantile cerebral palsy
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CSHCN Services Program Providers
• Cystic fibrosis
• Dysphagia
• Major trauma and burns
• Nutritional deficiencies (e.g., severe malnutrition, significant weight loss, low birth weight status)
• Inborn errors of amino acid metabolism
• Gastrostomy status or artificial opening of GI tract
• Metabolic disorder
• Immunity disorder
Note: Permanent impairment does not require a determination that there is no possibility that the client’s condition may
improve in the future. If medical documentation substantiates that the impairment can reasonably be expected to exceed
3 months (90 days), the test of permanence is considered met. This is consistent with Center for Medicare and Medicaid
Services (CMS) guidelines.
Prior authorization for other conditions must be reviewed by the CSHCN Services Program Medical Director or
designee.
Refer to: The CSHCN Services Program Provider Manual, subsection 26.5.2.1, “Prior Authorization Requirements,”
for additional information.
Medications-Blood Factor Products
Providers may be reimbursed for blood factor products when the most appropriate procedure code is submitted with
one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D66
D67
D680
D681
D682
D68311
D684
D688
D689
Z1402
Procedure codes J7180, J7181and J7200 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D682
D688
D689
Procedure codes C9136 and J7201 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D66
D682
D688
D689
Procedure code J7183 may be reimbursed when submitted with the following ICD-10-CM diagnosis code:
Diagnosis Code (Submitted as stand-alone diagnosis code)
D680
Procedure codes J7193, J7194, and J7195 may be reimbursed when submitted with diagnosis code D67.
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CSHCN Services Program Providers
Procedure code J7189 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D66
D67
D682
D68311
D684
D688
D689
Z1402
Procedure codes J7186 and J7187 may be reimbursed when they are submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D66
D680
Procedure codes J7185, J7190, J7192 and J7198 may be reimbursed when they are submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
D66
D67
D681
D682
D68311
D688
D689
Providers can refer to the CSHCN Services Program Provider Manual, subsection 31.2.8, “Blood Factor Products,”
and subsection 24.4.1.1, “Blood Factor Products,” for additional information.
Medications – Growth Hormone
A valid ICD-10-CM diagnosis code must be submitted on claims for growth hormone (hGH) injections, and must
indicate one of the following conditions:
• Chronic kidney disease
• Pituitary gland insufficiency
• Prader-Willi syndrome
• Turner syndrome
• Other specified disorders resulting from impaired renal function
Refer to: The CSHCN Services Program Provider Manual, Section 31 “Physician,” subsection 31.2.24.7 “Growth
Hormone” for additional information.
Nebulizers
Effective for dates of service on or after October 1, 2015, a nebulizer with compressor or an ultrasonic nebulizer
may be purchased for clients when the equipment is prescribed by a physician and submitted with one of the
following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8411
E8419
E848
E849
J200
J205
J206
J207
J208
J209
J210
J441
J449
J4520
J4521
J4522
J4530
J4542
J4550
J4551
J4552
J45901
J45902
J690
J691
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J201
J211
J4531
J45909
J202
J218
J4532
J45998
J203
J219
J4540
J471
J204
J440
J4541
J479
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CSHCN Services Program Providers
Ultrasonic Nebulizer Related Diagnosis Codes
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B20
B59
E840
E8411
E8419
E848
E849
Refer to: The CSHCN Services Program Provider Manual, 35.2.8 “Nebulizers” for additional information.
Neurostimulators and Neuromuscular Stimulators
Prior authorization is not required for the purchase and implantation of a dorsal column neurostimulation (DCN),
Intracranial neurostimulation (ICN), or percutaneous electrical nerve stimulation (PENS) device if the client has
been diagnosed with one of the following:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G129
G20
G250
G251
G252
G500
G501
G5771
G5772
G8921
G8928
G8929
G893
M4321
M4322
M4323
M4324
M4325
M4326
M4327
M4328
M438X9
M4800
M4801
M5021
M4807
M4808
M4806
M4804
M4805
M4802
M4803
M5022
M5023
M5410
M792
S48011S
S48012S
S48021S
S48022S
S48111S
S48112S
S48121S
S48122S
S48911S
S48912S
S48921S
S48922S
S58011S
S58012S
S58021S
S58022S
S58111S
S58112S
S58121S
S58122S
S58911S
S58912S
S58921S
S58922S
S68011S
S68012S
S68021S
S68022S
S68110S
S68111S
S68112S
S68113S
S68114S
S68115S
S68116S
S68117S
S68120S
S68121S
S68122S
S68123S
S68124S
S68125S
S68126S
S68127S
S68128S
S68411S
S68412S
S68421S
S68511S
S68512S
S68521S
S68522S
S68610S
S68611S
S68612S
S68613S
S68614S
S68615S
S68616S
S68617S
S68621S
S68622S
S68623S
S68624S
S68625S
S68626S
S68627S
S68712S
S68721S
S68722S
S78011S
S78012S
S78021S
S78022S
S78111S
S78112S
S78121S
S78122S
S78911S
S78912S
S78921S
S78922S
S78929S
S88011S
S88012S
S88021S
S88022S
S88111S
S88112S
S88121S
S88122S
S88911S
S88912S
S88921S
S88922S
S98011S
S98012S
S98021S
S98022S
S98111S
S98112S
S98121S
S98122S
S98131S
S98132S
S98141S
S98211S
S98221S
S98222S
S98311S
S98312S
S98321S
S98322S
S98911S
S98912S
S98921S
Prior Authorization
PENS
Prior authorization for PENS is not required for clients who meet the following criteria:
• The client has a diagnosis indicating chronic pain that is refractory to conventional therapy.
• Treatment with transcutaneous electrical nerve stimulation (TENS) has failed or is contraindicated for the client.
Prior authorization for the implantation and purchase of DCN or ICN devices may be considered with a condition
indication chronic pain that is refractory to conventional therapy.
Vagal Nerve Stimulation (VNS)
Prior authorization for the implantation and purchase of VNS devices may be considered for clients with partial
onset intractable seizures when there is a failure, contraindication or intolerance to all suitable medical and
pharmacological management.
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CSHCN Services Program Providers
Sacral Nerve Stimulation (SNS)
Prior authorization for the implantation and purchase of SNS devices may be considered with one of the following
medical conditions:
• Urinary incontinence secondary to urethral instability
• Chronic voiding dysfunction
• Non-obstructive urinary retention
• Fecal incontinence
Refer to: The CSHCN Services Program Provider Manual, Section 27, “Neurostimulator Devices and Supplies,” for
additional information.
Physician Evaluation and Management Services: Concurrent Inpatient Care
Concurrent care will not be paid to providers of the same specialty for the same or related diagnoses. Concurrent
care that is denied will be considered on appeal when the appeal is accompanied by documentation of medical
necessity.
Diagnosis codes are considered related when up to six digits of the primary ICD-10-CM diagnosis codes match.
Refer to: The CSHCN Services Program Provider Manual, 31.2.17.2 “Inpatient Professional Services”for additional
information.
Positron Emission Tomography (PET)
PET procedure code 78608 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis
codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G40201
G40209
G40211
G40219
R569
PET procedure codes 78811, 78812, and 78813 may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C000
C001
C003
C004
C005
C006
C008
C430
C4311
C4312
C4321
C4322
C4330
C4331
C4339
C434
C4351
C4352
C4359
C4361
C4362
C4371
C4372
C438
C439
C4400
C4409
C44102
C44109
C44112
C44119
C44122
C44129
C44192
C44199
C44202
C44209
C44292
C44299
C44301
C44309
C44390
C44391
C44399
C4440
C4449
C44500
C44501
C44509
C44590
C44591
C44599
C44602
C44609
C44692
C44699
C44702
C44709
C44792
C44799
C4480
C4489
C4490
C4499
C518
C6201
C6202
C6210
C6291
C6292
C710
C711
C712
C713
C714
C715
C716
C717
C718
C719
C7641
C7642
C792
C7931
D030
D0311
D0312
D0321
D0322
D0330
D0339
D034
D0351
D0352
D0359
D0361
D0362
D0371
D0372
D038
D039
D4011
D4012
D430
D431
D432
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CSHCN Services Program Providers
Refer to: The CSHCN Services Program Provider Manual, subsection 16.2.9 “Positron Emission Tomography
(PET)” for additional information.
Preventive Care Medical Checkups and Developmental Testing
The generally accepted schedule for preventive care medical checkups is seven to eight visits the first year, four visits
for 13 months through 30 months of age, and then annually thereafter.
Providers should submit claims with the most appropriate evaluation and management procedure code and include
the most appropriate ICD-10-CM diagnosis code as follows:
Client
Diagnosis Codes
Children visits
Z00121 or Z00129
Adult visits
Z0000 or Z0001
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.17.9, “Preventive Care Medical
Checkups and Developmental Testing,” for additional information.
Rabies Postexposure Treatment
Procedure codes 90375, 90376, and 90675 may be reimbursed when they are submitted with the following
ICD-10-CM diagnosis code:
Diagnosis Code (Submitted as stand-alone diagnosis code)
Z203
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.23.14 “Rabies Postexposure Prophylaxis,”
for additional information.
Renal Dialysis Services
Renal dialysis services must be submitted with the most appropriate ICD-10-CM diagnosis code that indicates one
of the following acute or chronic clinical indications:
Acute indications for dialysis are as follows:
• Metabolic acidosis
• Electrolyte imbalance
• Drug overdose with dialysable toxin
• Fluid overload
• Complications of uremia
Chronic indications for dialysis are as follows:
• Symptomatic renal failure
• Low glomerular filtration rate (GFR)
• Difficulty in controlling fluid overload or electrolyte imbalance
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Procedure code G0257 may be reimbursed for services rendered to clients with stage V chronic kidney disease and
end-stage renal disease (ESRD).
Refer to: The CSHCN Services Program Provider Manual, Section 34.3, “Benefits, Limitations, and Authorization
Requirements, for additional information.
Respiratory Equipment and Supplies
Providers must submit claims for respiratory equipment and supplies procedure codes with the most appropriate
ICD-10-CM diagnosis codes as indicated below.
Cardiorespiratory (Apnea) Monitors
Cardiorespiratory (apnea) monitors for infants who are birth through three months of age may be reimbursed
without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G9009
I440
I441
I442
I4430
I4439
I471
I479
I498
K210
K219
P228
P270
P271
P278
P282
P283
P284
P285
P2889
P2912
Q246
R000
R0681
Z8489
P2911
Prior authorization for the purchase of a high frequency chest wall compression system (HFCWCS) may be considered when the request is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8411
E8419
E848
E849
G121
G128
G129
G710
G800
G801
G802
G804
G808
G809
Other diagnoses will be considered with documentation of medical necessity.
Prior authorization is not required for a large volume nebulizer with compressor when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E840
E8411
E8419
E848
E849
J398
J471
J479
J9809
Z430
Z930
Prior authorization is not required for a filtered nebulizer or related compressor when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
B20
T8690
T8691
T8692
T8693
T8699
Prior authorization is not required for a controlled dose inhalation drug delivery system when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
I272
I2789
Prior authorization is not required for a small volume nebulizer with related compressor when the most appropriate
procedure code is submitted with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A3701
A3711
A3781
A3791
A481
B20
E8411
E8419
E848
E849
J09X1
J09X2
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B250
J120
B440
J121
B59
J122
E840
J123
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CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
J1281
J1289
J129
J13
J14
J150
J1529
J153
J154
J155
J156
J157
J17
J180
J181
J188
J189
J210
J441
J449
J4520
J4521
J4522
J4530
J4542
J4550
J4551
J4552
J45901
J45902
J690
J691
Q334
T8601
T8602
T8603
T8619
T8621
T8622
T8623
T86290 T86298
T86810
T86811
T86812 T86818
T86830 T86831
T86852 T86858 T86890 T86891 T86892 T86898
T8699
J151
J158
J211
J4531
J45909
T8609
T8641
T86832
T8690
J1520
J159
J218
J4532
J45990
T8611
T8642
T86838
T8691
J15211
J160
J219
J4540
J45991
T8612
T8643
T86850
T8692
J15212
J168
J440
J4541
J45998
T8613
T8649
T86851
T8693
Refer to: The CSHCN Services Program Provider Manual, Section 35 “Respiratory Equipment and Supplies” for
additional information.
Rhizotomy
Procedure code 63185 or 63190 may be reimbursed when they are submitted with one of the following ICD-10-CM
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G800
G801
G802
G808
G809
G835
G8389
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.36.14, “Rhizotomy,” for additional
information.
Sleep Studies
Procedure code 94772 (Pediatric Pneumogram) may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
K208
K209
K210
K219
K220
P220
P228
P229
P270
P271
P278
P279
P282
P283
P284
P285
P2881
P2889
P84
R0600
R0609
R062
R063
R0681
R0682
R0683
R0689
R069
R6813
Procedure code 95805 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes
as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E662
G4700
G4710
G4711
G4712
G4720
G4733
G47411
G47419
G47421
G47429
G478
G479
Procedure codes 95782, 95783, 95808, 95810, and 95811 may be reimbursed when they are submitted with one of
the following ICD-10-CM diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
E662
F5101
F5102
F5103
F5104
F5109
F5111
F5112
F5113
F5119
F513
F514
F515
F518
F519
F984
G253
G2589
G259
G26
G4700
G4701
G4710
G4711
G4712
G4713
G4714
G4719
G4720
G4721
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CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
G4722
G4723
G4724
G4725
G4726
G4727
G4734
G4735
G4736
G4737
G4739
G47411
G4751
G4752
G4753
G4754
G4759
G4761
J9611
J9612
R0600
R0609
R063
R0683
G4729
G47419
G4769
R0689
G4730
G47421
G478
R069
G4731
G47429
G479
R0901
G4733
G4750
J9610
Refer to: The CSHCN Services Program Provider Manual, subsection 24.4.1.4, “Sleep Studies,” for additional
information.
Therapeutic Apheresis
Therapeutic apheresis procedure codes 36511, 36512, 36513, and 36514, and apheresis with extracorporeal affinity
adsorption and plasma reinfusion procedure codes 36515 and 36516 may be reimbursed when they are submitted
with one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
C888
C9000
C882
C883
C880
C9020
C9022
C9030
C9032
C9100
C9130
C9132
C9140
C9142
C9150
C9190
C9192
C91A0
C91A2
C91Z0
C9220
C9230
C9232
C9240
C9210
C9260
C9262
C9290
C9292
C92A0
C9300
C9302
C9310
C9312
C9330
C93Z0
C93Z2
C9400
C9402
C9420
C9440
C9442
C9480
C9482
C9500
C9590
C9592
D45
D472
D473
D5702
D571
D5720
D57211
D57212
D57812
D57819
D588
D589
D590
D594
D599
D6182
D65
D682
D691
D692
D693
D6941
D6942
D699
D72828
D740
D748
D749
D759
D761
D762
D763
D77
E0942
E1042
E1142
E780
G603
G620
G621
G622
G6281
G6282
G7000
G7001
G731
I00
I010
I773
I776
I7789
K716
K7200
K760
K762
K7689
K77
L100
L104
L105
L1081
L1089
L109
L943
M05011
M05012
M05021
M05022
M05042
M05051
M05052
M05061
M05062
M05411
M05412
M05421
M05422
M05431
M05451
M05452
M05461
M05462
M05471
M05612
M05621
M05622
M05631
M05632
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C9002
C9102
C9152
C91Z2
C9242
C92A2
C9332
C9422
C9502
D474
D57219
D591
D68311
D6949
D750
D890
G610
G63
I012
K7201
L101
L900
M05031
M05071
M05432
M05472
M05641
C9010
C9110
C9160
C9200
C9250
C92Z0
C9390
C9430
C9510
D5700
D5780
D592
D688
D696
D751
D892
G6181
G64
I018
K7581
L102
L940
M05032
M05072
M05441
M0549
M05642
C9012
C9112
C9162
C9202
C9252
C92Z2
C9392
C9432
C9512
D5701
D57811
D593
D690
D698
D7589
E0842
G6189
G650
I019
K759
L103
L941
M05041
M0509
M05442
M05611
M05651
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CPT only copyright 2014 American Medical Association. All rights reserved.
CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
M05652
M05661
M05662
M05671
M05672
M08012
M08021
M08022
M08031
M08032
M08052
M08061
M08062
M08071
M08072
M08412
M08421
M08422
M08431
M08432
M08452
M08461
M08462
M08471
M08472
M08842
M08851
M08852
M08861
M08931
M08951
M08952
M08961
M08962
M310
M3219
M328
M3300
M3301
M3302
M3312
M3319
M3320
M3321
M3322
M3392
M3399
M340
M341
M342
M3489
N000
N001
N002
N003
N007
N008
N010
N011
N012
N016
N017
N018
N032
N034
N042
N044
N045
N046
N047
N053
N054
N055
N056
N058
N172
T8690
T8691
T8692
T8699
M0569
M08041
M0809
M08441
M0848
M08932
M311
M3309
M3329
M3481
N004
N013
N035
N048
N059
M069
M08042
M083
M08442
M08832
M08941
M320
M3310
M3390
M3482
N005
N014
N037
N049
N08
M08011
M08051
M08411
M08451
M08841
M08942
M3210
M3311
M3391
M3483
N006
N015
N040
N052
N171
Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.37, “Therapeutic Apheresis,” for
additional information.
Total Parenteral Nutrition (TPN)
Prior authorization for TPN must be submitted with the most appropriate ICD-10-CM diagnosis code or combination diagnosis codes as indicated. Prior authorization for TPN may be considered for clients with one of the
following conditions:
• Anatomical, physiological, or motility disorder of the gastrointestinal tract
• Prolonged bowel rest
• Gastrointestinal fistula
• Malignancies
• Inborn errors of amino acid metabolism
• Cystic Fibrosis
• Major trauma and burns
• Severe malnutrition, significant weight loss and/or hypoproteinaemia when enteral therapy is not possible
• Other disease states or conditions in which oral or enteral feeding are not an option
Prior authorization requests for clients with conditions other than those listed above will be forwarded to the
CSHCN Services Program Medical Director or designee for consideration.
Refer to: The CSHCN Services Program Provider Manual, subsection 26.6.2.1 “Prior Authorization
Requirements”for additional information.
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CSHCN Services Program Providers
Vaccines and Toxoids
For immunizations during an initial or follow-up office visit for a medical condition, the following may be
reimbursed when an appropriate medical ICD-10-CM diagnosis is submitted with the claim:
• The office visit
• The vaccines and toxoids that are not obtained through TVFC
• The administration fee
When the client visit is only for immunization, the office visit will not be reimbursed. The administration fee and
any vaccine/toxoid not obtained through TVFC may be reimbursed when ICD-10-CM diagnosis code Z23 referencing an immunization is submitted with the claim.
All immunizations must be reported with diagnosis code Z23. The type of immunization given will be identified by
the procedure code.
BCG vaccine (procedure code 90585) may be reimbursed when submitted with diagnosis code Z23.
Botulinum antitoxin procedure code 90287 may be reimbursed when submitted with one of the following
ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
A051
A4851
A4852
T50901A
T50901D
T50902S
T50903A
T50903D
T50903S
T50904A
T50991D
T50991S
T50992A
T50992D
T50992S
T50994A
T50994D
T50994S
T50Z91A
T50Z91D
T50Z92S
T50Z93A
T50Z93D
T50Z93S
T50Z94A
T50901S
T50904D
T50993A
T50Z91S
T50Z94D
T50902A
T50904S
T50993D
T50Z92A
T50Z94S
T50902D
T50991A
T50993S
T50Z92D
Refer to: The CSHCN Services Program Provider Manual, Children’s Services Handbook, Section 31 “Immunizations (Vaccines and Toxoids),” for additional information.
Vision Services Nonsurgical
Prior authorization is not required for the prescription, eyewear, and fitting of one medically necessary pair of
prescription eyeglasses (including frames and lenses) or one pair of contact lenses per calendar year if they are
prescribed for one of the following ICD-10-CM diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H18601 H18602 H18603 H18611
H18612 H18613
H2702
H2703
H27111 H27112 H27113 H27121
H27133 H35101 H35102 H35103 H35141 H35142
H35161 H35162 H35163 H35171 H35172 H35173
H5202
H5203
H5211
H5212
H5213
H52201
H52213 H52221 H52222 H52223 H5231
H5232
H53011 H53012 H53013 H53021 H53022 H53023
Q134
Z961
H18621
H27122
H35143
H4421
H52202
H524
H53031
H18622
H27123
H35151
H4422
H52203
H53001
H53032
H18623
H27131
H35152
H4423
H52211
H53002
H53033
H2701
H27132
H35153
H5201
H52212
H53003
Q123
Authorization is required for medically necessary eyeglasses or contact lenses and their prescriptions and fittings
within the same calendar year for diagnoses not listed in the above table. Requests for authorization must be
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CSHCN Services Program Providers
submitted using a CSHCN Services Program Authorization and Prior Authorization Request with the required
documentation that includes proof of medical necessity.
Vision examinations with refraction (for the purpose of obtaining a prescription for eyewear) may be reimbursed
once per calendar year and may be performed by ophthalmologists or optometrists. Vision examinations with
refraction should be billed using procedure code S0620 or S0621, and is limited to the following diagnoses:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H18821
H18822
H18823
H269
H4421
H4422
H4423
H5201
H5202
H5203
H5211
H5212
H5213
H52201
H52202
H52203
H52211
H52212
H52213
H52221
H52222
H52223
H5231
H5232
H524
H52511
H52512
H52513
H52521
H52522
H52523
H52531
H52532
H52533
H526
H527
Z0100
Z0101
Polarization of lenses procedure code V2762 may be reimbursed when it is billed with one of the following
diagnosis codes:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H2701
H2702
H2703
H27121
H27122
H27123
H27131
H27132
H27133
H5089
Q123
Z961
Computerized corneal topography procedure code 92025 may be reimbursed when it is submitted with one of the
following ICD-10-CM diagnosis codes as indicated:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H10211
H10212
H10213
H10811
H10812
H10813
H11001
H11002
H11003
H11011
H11012
H11013
H11021
H11022
H11023
H11031
H11032
H11033
H11041
H11042
H11043
H11051
H11052
H11053
H11061
H11062
H11063
H1189
H16001
H16002
H16003
H16011
H16012
H16013
H16021
H16022
H16023
H16031
H16032
H16033
H16041
H16042
H16043
H16051
H16052
H16053
H16061
H16062
H16063
H16071
H16072
H16073
H16101
H16102
H16103
H16111
H16112
H16113
H16121
H16122
H16123
H16131
H16132
H16133
H16141
H16142
H16143
H16201
H16202
H16203
H16211
H16212
H16213
H16221
H16222
H16223
H16231
H16232
H16233
H16251
H16252
H16253
H16261
H16262
H16263
H16291
H16292
H16293
H16301
H16302
H16303
H16311
H16312
H16313
H16321
H16322
H16323
H16331
H16332
H16333
H16391
H16392
H16393
H16401
H16402
H16403
H16411
H16412
H16413
H16421
H16422
H16423
H16431
H16432
H16433
H16441
H16442
H16443
H168
H169
H1701
H1702
H1703
H1711
H1712
H1713
H17811
H17812
H17813
H17821
H17822
H17823
H1789
H179
H1811
H1812
H1813
H1820
H18221
H18222
H18223
H18231
H18232
H18233
H1840
H18451
H18452
H18453
H18461
H18462
H18463
H1849
H1850
H1851
H1852
H1853
H1854
H1855
H1859
H18601
H18602
H18603
H18611
H18612
H18613
H18621
H18622
H18623
H1870
H18711
H18712
H18713
H18721
H18722
H18723
H18731
H18732
H18733
H18791
H18792
H18793
H18831
H18832
H18833
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CSHCN Services Program Providers
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H52201
H52202
H52203
H52211
H52212
L513
Q134
S0521XA
S0521XD
S0521XS
S0531XA
S0531XD
S0531XS
S0532XA
S0532XD
T2611XS
T2612XA
T2612XD
T2612XS
T2661XA
T2662XD
T2662XS
T85310A
T85310D
T85310S
T85318A
T85318D
T85318S
T85320A
T85320D
T85321S
T85328A
T85328D
T85328S
T85390A
T85391D
T85391S
T85398A
T85398D
T85398S
Z9842
Z9849
Z9883
H52213
S0522XA
S0532XS
T2661XD
T85311A
T85320S
T85390D
Z48810
Contact lenses and their prescription and fitting are limited to the following diagnoses:
Diagnosis Codes (Submitted as stand-alone diagnosis codes)
H18601
H18602
H18603
H18611
H18612
H18613
H18623
H2701
H2702
H2703
H27111
H27112
H27123
H27131
H27132
H27133
H35101
H27122
H35153
H35152
H35143
H35151
H35141
H35142
H35163
H35171
H35172
H35173
H4421
H4422
H5202
H5203
H5211
H5212
H5213
H52201
H52211
H52212
H52213
H52221
H52222
H52223
H524
H53001
H53002
H53003
H53011
H53012
H53022
H53023
H53031
H53032
H53033
Q123
L511
S0522XD
T2611XA
T2661XS
T85311D
T85321A
T85390S
Z947
L512
S0522XS
T2611XD
T2662XA
T85311S
T85321D
T85391A
Z9841
H18621
H27113
H35102
H35161
H4423
H52202
H5231
H53013
Q134
H18622
H27121
H35103
H35162
H5201
H52203
H5232
H53021
Z961
Refer to: The CSHCN Services Program Provider Manual, Section 39 “Vision Services,” for additional information.
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CSHCN Services Program Forms
CSHCN SERVICES PROGRAM FORMS
Changes to Forms
Effective for dates of service on or after October 1, 2015, the following CSHCN Services Program forms have been
revised to accommodate the changes associated with ICD-10. These forms must be used to request prior authorizations/authorization for services to be rendered on or after October 1, 2015. Previous versions of the forms can be
submitted for dates of service on or before September 30, 2015. Effective October 1, 2015, TMHP will no longer
accept the previous versions of the forms.
Claim Forms
The following claim forms and instructions have been revised:
• CMS-1500 claim form example and ICD-10 relevant instructions
• UB-04 claim form example and ICD-10 relevant instructions
Prior Authorization Forms
The following prior authorization forms have been revised:
• CSHCN Apnea Monitor Request Form and Instructions
• CSHCN Request for Augmentative Communication Devices (ACDs) Form and Instructions
• CSHCN Request for Chest Physiotherapy Devices Form and Instructions
• CSHCN Request for Dental or Orthodontia Services Form and Instructions
• CSHCN Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions
• CSHCN Durable Medical Equipment (DME) Form and Instructions
• CSHCN Request for External Insulin Pump Form and Instructions
• CSHCN Instructions for Prior Authorization Request for Hospice Services
• CSHCN Inpatient Pyschiatric Care Form and Instructions
• CSHCN Request for Inpatient Admission
• CSHCN Request for Inpatient Rehabilitation Admission Form and Instructions
• CSHCN Request for Medical Foods Form and Instructions
• CSHCN Medical Nutritional Services Form and Instructions
• CSHCN Request for Omalizumab Form and Instructions
• Texas Medicaid/CHIP Vendor Drug Program CSHCN Synagis® Request Form 2014-15 Season
• CSHCN Request for Pulse Oximeter Devices Form and Instructions
• CSHCN Renal Dialysis Treatment Form and Instructions
• CSHCN Respiratory Care Request Form
• CSHCN Stem Cell or Renal Transplant Request Form
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CSHCN Services Program Forms
• CSHCN Inpatient Surgery Request Form
• CSHCN Outpatient Surgery Request Form
• CSHCN Blood Factor Products
• CSHCN Non-Face-to-Face Clinician Directed Care Request Form
• CSHCN Request for Extension of Outpatient Therapy (TP2)
• CSHCN Request for Initial Outpatient Therapy (TP1)
• CSHCN Request for Authorization and Prior Authorization Form and Instructions
• CSHCN Documentation of Receipt
• CSHCN Documentation of Receipt (Spanish)
• CSHCN Home Health (Skilled Nursing) Referral and Treatment Plan
• CSHCN Wheelchair Seating Evaluation Form and Instructions
ICD-10 Special Bulletin, No. 8
145
2015 Texas Medicaid
CPT only copyright 2014 American Medical Association. All rights reserved.