January 11, 2018
Effective January 1, 2018, Texas Health and Human Services (HHS) requires lab providers to use two new procedure codes, 86794 and 87662, when submitting a fee-for-service claim for Zika virus testing. The Medicaid provider notification can be found at: http://www.tmhp.com/News_Items/2017/12-Dec/12-29-17%202018%20Healthcare%20Common%20Procedure%20Coding%20System%20Special%20Bulletin.pdf.
Previously, HHS had required providers to include modifier U4 with procedure code 86790, 87798, or 87799, when submitting a fee-for-service claim for Zika virus testing. As of 1/1/2018, these codes with modifier U4 will no longer be outlined in the TMPPM for the reimbursement of Zika virus testing.
HHS expects managed care organizations (MCOs) to implement procedure codes 86794 and 87662 in their claims systems on or before January 1, 2018 and to require lab providers to use these codes when submitting a claim for Zika testing. HHS expects these codes to be reflected in encounter data.
HHS will also require MCOs to reimburse Zika testing claims with these codes without prior authorization.
Providers are expected to use clinical judgement and follow recommendations from the Department for State Health Services (DSHS) regarding testing. These guidelines can be found at TexasZika.org.