Clinician-Administered Drugs

Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program may reimburse providers only for clinician-administered drugs and biologicals whose manufacturers participate in the Centers for Medicare and Medicaid Services (CMS) Drug Rebate Program and shown as active on the CMS list for the date of service the drug is administered. Clinician-administered drugs without a rebate-eligible National Drug Code (NDC) will not be reimbursed by Texas Medicaid or the CSHCN Services Program. There may be ingredients in a compound not considered a drug under the Federal Food, Drug, and Cosmetic Act.

NDC-to-HCPCS Information

The Texas NDC-to-HCPCS Crosswalk identifies relationships between National Drug Codes (NDC) and Medicaid-payable Healthcare Common Procedure Coding System (HCPCS) codes. The crosswalk assists with billing and coding and is a reference for converting HCPCS billing units to valid NDC unit calculations. The crosswalk is published quarterly and based on revisions to the CMS list of rebate-eligible drugs and new drugs and biologicals added to First Databank.

Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program may reimburse providers only for clinician-administered drugs and biologicals whose manufacturers participate in the CMS Drug Rebate Program and shows as active on the CMS list for the date of service the drug is administered. Clinician-administered drugs without a rebate-eligible NDC are not reimbursed by either program.

Relationship start dates do not indicate when the drug is approved by Medicaid for payment. These dates are populated from the CMS file of FDA-approved drugs and biologicals published quarterly and are a reference to that file. The inclusion of a HCPCS code and NDC on the crosswalk does not guarantee coverage or payment. For a drug or biologic to be reimbursed by Medicaid, the HCPCS and NDC must be listed on the crosswalk in effect on the date of service and a payable rate must be listed on the TMHP Fee Schedule. After consulting the crosswalk for HCPCS-NDC approved relationships, refer to the TMHP Fee Schedule to ensure the procedure is payable for the submitted program. Manually priced drugs, such as those covered under a miscellaneous code, may not appear as payable on the Fee Schedule. New and revised reimbursement rates for drugs payable under HCPCS codes are developed by the HHSC Provider Finance Department and published by TMHP.