Medi-Cal Update

Community - Based Adult Services (formerly Adult Day Health Care Centers) | September 2017 | Bulletin 516

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1. 2017 CPT-4/HCPCS Annual Update: Manual Replacement Page Release

The 2017 updates to the Current Procedural Terminology – 4th edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2017 CPT-4/HCPCS Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions will be effective for dates of service on or after October 1, 2017. Please refer to the 2017 CPT-4 and HCPCS Level II code books for complete descriptions of these codes.

Additionally, the 2017 CPT-4 codebook was updated to allow separate reimbursement for moderate (conscious) sedation for multiple codes that had previously included moderate (conscious) sedation as an inherent part of providing the procedure. Please refer to the 2017 CPT-4 codebook for instructions on how to bill for this service with other codes.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
medi cr op pr (7)
Audiology and Hearing Aids tax (7, 8)
Chronic Dialysis Clinics immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); medi non cpt (1, 2); modif used (4–7, 9–12); non inject (9–11); path bil (1, 4–7, 9); path organ (9); vaccine (2–4, 9)
Clinics and Hospitals altern (3); anest (11, 13, 16, 28); cardio (14–16, 19); chemo drug a-d (8, 9, 21); chemo drug e-o (2, 3, 10, 11, 17); chemo drug p-z (10, 12–14, 18); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); medi non cpt (1, 2); medne non (1); medne oto (4); medne tele (4, 5); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); ophthal (2); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); respir (4, 7); surg (2, 5); surg bil mod (7, 8); surg bill ub (5, 6, 10, 11); surg cardio (2, 3, 9); surg integ (4, 5); surg muscu (1, 7); surg nerv (1); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Durable Medical Equipment dura bil wheel (4, 5); dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho cd1 (12–14); ortho cd fre1 (1, 2); respir (4, 7); tax (7, 8)
General Medicine altern (3); anest (11, 13, 16, 28); cardio (14–16, 19); chemo drug a-d (8, 9, 21); chemo drug e-o (2, 3, 10, 11, 17); chemo drug p-z (10, 12–14, 18); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi non cpt (1, 2); medne non (1); medne oto (4); medne tele (4, 5); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); ophthal (2); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); respir (4, 7); surg (2, 5); surg bil cms (4, 5, 8, 9); surg bil mod (7, 8); surg cardio (2, 3, 9); surg integ (4, 5); surg muscu (1, 7); surg nerv (1); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Inpatient Services tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8)
Obstetrics altern (3); anest (11, 13, 16, 28); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi non cpt (1, 2); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); surg (2, 5); surg bil cms (4, 5, 8, 9); surg bil mod (7, 8); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Orthotics and Prosthetics dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho (22); ortho cd1 (12–14); ortho cd fre1 (1, 2); tax (7, 8)
Pharmacy dura bil wheel (4, 5); dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8, 9, 10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); ortho (22); ortho cd1 (12–14); ortho cd fre1 (1, 2); presum (10, 15, 17, 18); tax (7, 8)
Psychological Services psychol cd (1); psychol ex (2)
Rehabilitation Clinics immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); respir (4, 7); vaccine (2–4, 9)
Therapies dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho cd1 (12–14); ortho cd fre1 (1, 2); respir (4, 7)
Vision Care medi non cpt (1, 2)
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2. End of Life Option Act Transitioning to HIPAA-Compliant Billing Code Set

Effective for dates of service on or after October 1, 2017, End of Life Option Act services are billed with a HIPAA-compliant billing code set as detailed below.

Provider Type Revenue Code Procedure Code
Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) 0521 S0257
Indian Health Services-Memorandum of Agreement (IHS-MOA) 0520 S0257

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Clinics and Hospitals
ind health cd (8); rural cd (9)
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3. FQHC/RHC/IHS-MOA Code Conversion Policy Overview

Effective for dates of service on or after October 1, 2017, Service Authorization Requests (SARs) and claims billed with HCPCS Level III local FQHC/RHC/IHS-MOA codes will no longer be eligible for reimbursement.

Providers submitting SARs with dates of service on or after October 1, 2017, must include the appropriate HIPAA-compliant billing code sets described in the following crosswalks announced in January 2017:

Providers should review their inventory for previously-approved SARs with FQHC/RHC/IHS-MOA services that have dates of services on or after October 1, 2017. For those SARs, providers must submit a new SAR with the appropriate billing code set to cover any remaining service period on or after October 1, 2017.

If a SAR is submitted for the purpose of updating codes in the same authorization period, it will not be reviewed for medical necessity.

In addition, the following Remittance Advice Details (RAD) codes are added to help reconcile provider accounts:

RAD Code Message
9269 Quantity exceeds allowed for the service.
9273 Quantity exceeds allowed for the service; medical justification required.
9274 Not payable due to another service paid on same date of service; medical justification required.
9280 Split bill claims for DOS before and after 10/01/2017.
9281 IPPE/AWV service not payable due to another IPPE/AWV service paid on same date of service.
9993 The service code combination is not valid for billing provider.

Provider Resources
Providers should refer to the FQHC/RHC/IHS-MOA section of the HIPAA: Code Conversions web page for a complete list of FQHC/RHC/IHS-MOA resources.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Expanded Access to Primary Care Program
General Medicine
Inpatient Services
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program Obstetrics
Orthotics and Prosthetics
Psychological Services
Therapies
Vision Care
hcpcs (2)
Adult Day Health Care Centers hcpcs (2); ind health (3–7); ind health cd (1–11); rural (7); rural cd (1–12); rural ex (2–4)
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Rehabilitation Clinics
medi cr op ex (6); hcpcs (2)
Clinics and Hospitals hcpcs (2); ind health (3–7); ind health cd (1–11); medi cr op ex (6); rural (7); rural cd (1–12); rural ex (2–4)
Part 1 remit cd9000 (24, 59); remit elect corr9200 (9–11); remit elect corr9900 (11); remit elect corr rarc (1–5)
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4. Update to IHS-MOA Provider Managed Care Differential Rate Billing

The claims processing system was recently modified to accommodate proper differential rate billing for Medi-Cal members enrolled in Medi-Cal managed care plans. Effective retroactively for dates of service on or after July 1, 2016, an update to policy for Indian Health Centers – Memorandum of Agreement (IHS-MOA) 638, regarding multiple daily billing of per-visit code 18 (managed care differential rate) applies: Providers may be reimbursed for three code 18 visits per day, per recipient, one medical visit, one mental health visit and one ambulatory visit or dental visit. These visits do not require medical justification in the Remarks field (Box 80) or on an attachment to the claim.

Providers need take no action. Claims with dates of service on or after July 1, 2016, that were previously denied will be reprocessed with an Erroneous Payment Correction (EPC).

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5. 2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines

A new DUR Educational Article titled “2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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6. October 2017 Medi-Cal Provider Seminar

The October Medi-Cal provider seminar is scheduled for October 17, 2017, at the Embassy Suites in San Luis Obispo, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, Department of Health Care Services (DHCS) and Conduent, the Fiscal Intermediary for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by October 3, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After October 3, 2017, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks Web page on the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers who require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative Web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.

Providers are encouraged to bookmark the Provider Training Web page and refer to it often for current seminar information.

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7. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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For more information about MCSS, please visit the MCSS Help page.

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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