Provider Alert! Prior Authorization Diagnosis Coding Reminder

Provider Alert!

Provider Alert! Prior Authorization Diagnosis Coding Reminder

Date: June 20, 2023
Attention: All Providers

Call to action: As a reminder, Texas Children’s Health Plan (TCHP) aligns with the Texas Medicaid Provider Procedure Manual (TMPPM) regarding the ICD-10-CM diagnosis-coding requirement on claim submissions.

Resource: TMPPM Section 6: Claims filing

How this impacts providers: Diagnosis codes guidance as outlined in the TMPPM are as follows:

  • Diagnosis codes must be to the highest level of specificity available
  • Diagnosis codes must be appropriate for the age of the client as identified in the ICD-10-CM description of the diagnosis code

Non-specific diagnosis codes have a negative impact on the 278 file that TCHP sends to Health and Human Services Commission. 

Next step for Providers: Providers must adhere to the guidelines in this communication on diagnosis- coding as part of the claim submission process. Claims that are denied by TCHP because one or more of the diagnosis codes submitted on the claim are not appropriate for the age of the client, or other reason, may be appealed with the correct diagnosis code or documentation of medical necessity to justify the use of the diagnosis code.

If you have any questions, please email Provider Relations at:

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