Medi-Cal Update

Community - Based Adult Services (formerly Adult Day Health Care Centers) | February 2018 | Bulletin 521

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1. Corrections to 2018 CPT-4/HCPCS Annual Update

A previously published Medi-Cal Update added, changed and deleted CPT-4 and HCPCS codes for the 2018 annual update, effective February 1, 2018, and the 2017 quarterly update, effective October 1, 2017. Updates to this policy are as follows:

The following HCPCS codes are not Presumptive Eligibility for Pregnant Women (PE4PW) benefits:

C9014 C9029 J0565 J2326 J9023
C9015 C9488 J0604 J2350 J9203
C9016 C9492 J0606 J3358 J9285
C9024 C9493 J1428 J7345 Q2040
C9028 C9738 J1555 J9022  

Durable Medical Equipment
HCPCS codes E0953 and E0954 are non-taxable and must be billed with modifiers NU, NURB/RBNU or RR.  Modifiers U7, J4 and 99 are allowed.

HCPCS code E0953 has a frequency limit of two every 12 months for any provider.  A Treatment Authorization Request (TAR) may be submitted to override the frequency limit.

HCPCS code E0954 has a frequency limit of two in five years for any provider.  A TAR may be submitted to override the frequency limit.

Medicine
CPT-4 code 94617 is split-billable with an approved TAR and must be billed with modifier TC when billing only for the technical component, and modifier 26 when billing only for the professional component. When billing for both the technical and professional component, no modifier is required. Modifier 99 must not be billed in conjunction with modifier 26 or modifier TC, otherwise the claim will be denied.

Physician Administered Drugs
The correct ICD-10-CM diagnosis codes for HCPCS code J2326 includes the range G12.20 – G12.25.

No frequency limitation is applicable to HCPCS code J7296.

Radiology
CPT-4 codes 71045 – 71048, 74018, 74019 and 74021 are split-billable with an approved TAR and must be billed with modifier TC when billing only for the technical component, and modifier 26 when billing only for the professional component. When billing for both the technical and professional component, no modifier is required. Modifier 99 must not be billed in conjunction with modifier 26 or modifier TC, otherwise the claim will be denied.

Surgery
CPT-4 code 36483 is exempt from the modifier 51 cutback.

CPT-4 code 58575 requires a hysterectomy informed consent form to be attached to the claim; otherwise the claim will be denied.

The correct policy is reflected in the following PDF documents:

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 ex (1); medi cr op pr (3)
Audiology and Hearing Aids tax (9)
Chronic Dialysis Clinics blood (7); immun (9); inject cd list (8); inject drug n-r (2); medi cr op ex (1); medi cr op pr (3); modif used (10); path cyto (1–4)
Clinics and Hospitals allergy (1); blood (7); ev woman exub (1, 2); fam planning (4); hyst (4); immun (9); inject cd list (8); inject drug n-r (2); medi cr op ex (1); medi cr op pr (3); medne pul (3); modif used (10); path cyto (1–4); path molec (2, 12, 13, 20–22, 42, 43); presum (17, 19); radi bil ub (1); radi dia (22); surg bil mod (7); surg female (2); surg lap (1); tar and non cd5 (6); tar and non cd9 (5)
Durable Medical Equipment
Orthotics and Prosthetics
dura cd fre (3); tax (9)
Family PACT drug (2, 7)
General Medicine allergy (1); blood (7); fam planning (4); hyst (4); immun (9); inject cd list (8); inject drug n-r (2); medi cr cms exm (1); medi cr cms prm (3); medne pul (3); modif used (10); path cyto (1–4); path molec (2, 12, 13, 20–22, 42, 43); presum (17, 19); radi bil cms (1); radi dia (22); surg bil mod (7); surg female (2); surg lap (1); tar and non cd5 (6); tar and non cd9 (5)
Inpatient Services hyst (4); tar and non cd5 (6); tar and non cd9 (5)
Obstetrics fam planning (4); hyst (4); immun (9); inject cd list (8); inject drug n-r (2); medi cr cms exm (1); medi cr cms prm (3); modif used (10); path cyto (1–4); path molec (2, 12, 13, 20–22, 42, 43); presum (17, 19); radi bil cms (1); radi dia (22); surg bil mod (7); surg female (2); surg lap (1); tar and non cd5 (6); tar and non cd9 (5)
Pharmacy blood (7); dura cd fre (3); immun (9); inject cd list (8); inject drug n-r (2); presum (17, 19); tax (9)
Rehabilitation Clinics immun (9); inject cd list (8); inject drug n-r (2); medi cr op ex (1); medi cr op pr (3); modif used (10)
Therapies dura cd fre (3)
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2. New Managed Care Payment Process for IHS-MOA

Effective for dates of service on or after January 1, 2018, Indian Health Services (IHS) – Memorandum of Agreement (MOA) 638, Clinics should no longer submit Medi-Cal managed care claims for services covered by Medi-Cal Managed Care Plans (MCPs). This includes claims for Medicare enrollees also enrolled in a Medi-Cal MCP.

IHS-MOA facilities must use the billing processes outlined below:

Revenue Code HCPCS Code Modifier
520
Managed care differential rate, covered by managed care and rendered to recipients enrolled in Medi-Cal managed care plans
T1015
Clinic visit/encounter, all-inclusive
SE
State and/or federally funded programs/services

IHS-MOA facilities are no longer required to submit claims for the MCP differential rate. Effective January 1, 2018, claims submitted with code set 520 T1015 SE will be adjudicated at a $0 payment:

All other claims – dental, Medi-Cal fee-for-service, carve-out managed care (services not covered by the MCP), Medicare crossover and Capitated Medicare Advantage Plan (for members not enrolled in a Medi-Cal MCP) – will continue to be adjudicated per current processes.

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 (5, 6); ind health cd (9, 10)
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3. Restored Outpatient Acupuncture Services for FQHC/RHC Providers

Effective retroactively for dates of service on or after July 1, 2016, outpatient acupuncture services for Federally Qualified Health Center and Rural Health Clinic (FQHC/RHC) providers are restored as acupuncture benefits provided to Medi-Cal recipients.

The following per-visit billing codes are restored (for dates of service through September 30, 2017):

Code Description
01 Medi-Cal per-visit code
15 Acupuncture
18 Managed care differential rate

Affected claims for dates of service on or after July 1, 2016, will be reprocessed with an Erroneous Payment Correction (EPC).

The following HIPAA-compliant code sets are available for billing on or after October 1, 2017:

Revenue Code Procedure Code Modifier Description
0521 T1015 N/A Medical Visit
2101 97810 SE Acupuncture Services
2101 97811 SE Acupuncture Services
2101 97813 SE Acupuncture Services
2101 97814 SE Acupuncture Services
0521 T1015 SE Managed Care Differential Rate

Providers will receive a 90 day timeliness override, effective the date of this publication, for billing acupuncture services for the dates of service described above.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Clinics and Hospitals
rural (3)
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4. Phase 2: RTD Generation to Be Discontinued

The Department of Health Care Services (DHCS) is phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1). The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. The first phase was implemented in November 2017 and the second phase was implemented in February 2018. The third phase is expected to implement in the second quarter of 2018. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. As DHCS transitions from the use of RTDs to claim denials, providers can expect to receive fewer RTDs. When the project is completed, the use of RTDs will be completely discontinued.

Providers are encouraged to routinely check the Medi-Cal website for more information.

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5. Diabetes Prevention Program Established for Medi-Cal

Effective July 10, 2017, Senate Bill 97 (Chapter 52, Statutes of 2017), requires the Department of Health Care Services (DHCS) to establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems, consistent with the guidelines provided by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

A core benefit of Medi-Cal's DPP will include 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. Participants who achieve and maintain a minimum weight loss of 5 percent by the conclusion of the 12 month period will also be eligible to receive ongoing maintenance sessions to help them continue healthy lifestyle behaviors. SB 97 also requires that Medi-Cal providers choosing to offer DPP services comply with CDC guidance and obtain CDC recognition in connection with the National DPP.

The benefit will be available to eligible Medi-Cal recipients on January 1, 2019. DHCS is working with its Managed Care Plans, the Department of Public Health, Public Health Advocates and other interested stakeholders to discuss policy implications and potential collaborations. DHCS will begin drafting its policy and submit a CMS State Plan Amendment in 2018. To join the stakeholder list and to submit questions or comments, email DHCSDPP@dhcs.ca.gov.

DHCS is conducting a provider survey to better understand how Medi-Cal providers discuss prediabetes with their patients and to receive any comments or concerns regarding Medi-Cal's DPP benefit. DHCS would appreciate provider's feedback through a short 10-minute survey.

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6. March 2018 Medi-Cal Provider Seminar

The next Medi-Cal provider seminar is scheduled for March 13, 2018, at the Red Lion Hotel Redding in Redding, 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, the Department of Health Care Services (DHCS) and the DHCS Fiscal Intermediary (FI) 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 and request by January 30, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After January 30, 2018, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web page of the Medi-Cal website.

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

Providers that 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 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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The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form
  2. Enter your email address and ZIP code and select a subscriber type
  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

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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