MedicaidCoverageHigh impact
Diagnosis Codes Added for Procedure Codes J3357 and J3358 Effective August 1, 2026
Texas Medicaid·TX · Dermatology, Gastroenterology, Rheumatology +1 more·General
Effective date
Aug 1, 2026
We identified it
Jul 28, 2026
Summary
Effective August 1, 2026, Texas Medicaid will require specific diagnosis codes to be submitted with Stelara claims (HCPCS codes J3357 and J3358). Claims must include at least one diagnosis code from the approved lists for Psoriasis Arthritis, Plaque Psoriasis, Crohn's Disease, or Ulcerative Colitis to receive reimbursement. Billing teams must update claim submission protocols and provider documentation requirements immediately.
Action Required
By July 15, 2026: Billing team must update billing software and claims submission protocols to require one diagnosis code from the approved lists (Psoriasis Arthritis L4050-L4059, Plaque Psoriasis L400-L409, Crohn's Disease K5000-K50919, or Ulcerative Colitis K5100-K51919) when submitting claims for Stelara (J3357, J3358). Providers must add a documentation checklist to encounter forms and EMR templates requiring diagnosis code selection for all Stelara administrations. Notify all providers and front desk staff that claims for J3357/J3358 submitted without one of these diagnosis codes will be denied by Texas Medicaid MCOs effective August 1, 2026. Confirm with each patient's specific MCO regarding any additional prior authorization requirements before the effective date.