Procedure Coding

HIPAA Claim: Procedure Coding (Texas Medicaid)

Texas Medicaid uses the Healthcare Common Procedure Coding System (HCPCS) for HIPAA Claim submission. HCPCS provides health-care providers and third-party payers a common coding structure that uses codes designed around a five-character numeric or alphanumeric base. The procedure codes are updated annually and quarterly.

HCPCS consists of two levels of codes:

  • Level I—Current Procedural Terminology (CPT®) Professional Edition
    • Numeric, five digits
    • Makes up 80 percent of HCPCS
    • Maintained by AMA, which updates it annually
    • Updates by the AMA are coordinated with CMS before modifications are distributed to thirdparty payers
    • Anesthesia codes from CPT
  • Level II—HCPCS Approved and released by CMS
    • Codes for both physician and non-physician services not contained in CPT (for example, ambulance, DME, prosthetics, and some medical codes)
    • Maintained and updated by the CMS Maintenance Task Force
    • Alphanumeric, a single alpha character (A through V) followed by four digits.

HCPCS Updates

TMHP updates HCPCS codes on both an annual and quarterly basis. Major updates are made annually and minor updates are made quarterly. Most of the procedure codes that do not replace a discontinued procedure code must go through the rate hearing process. HHSC conducts public rate hearings to provide an opportunity for the provider community to comment on the Medicaid proposed payment rate, as required by Chapter 32 of the Human Resources Code, §32.0282, and Title 1 of the Texas Administrative Code, §355.201.

Annual HCPCS updates apply additions, changes, and deletions that include the program and coding changes related to the annual HCPCS, Current Dental Terminology (CDT), and CPT updates. These updates ensure that the coding structure is up-to-date by using the latest edition of the CPT and the nationally established HCPCS codes that are released by CMS.

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