Medi-Cal Update

AIDS Waiver Program | November 2017 | Bulletin 518

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1. Increased Reimbursement Rates for AIDS Waiver Program

Effective for dates of service on or after July 1, 2017, the AIDS Medi-Cal Waiver Program (MCWP) has increased reimbursement rates for several HCPCS and CPT-4 codes. The updated rates are as follows:

CPT-4 or HCPCS Code Description Maximum Rate
90837 Psychotherapy, 60 minutes with patient $ 98.02
per hour
90846 Family psychotherapy (without the patient present), 50 minutes 98.02
per hour
90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes 98.02
per hour
G0156 Services of home health/hospice aide in home health or hospice settings (attendant care), each 15 minutes 9.52
per 15 minutes
G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes 19.27
per 15 minutes
G0300 Direct skilled nursing services of a license practical/vocational nurse (LPN/LVN) in the home health or hospice setting, each 15 minutes 13.97
per 15 minutes
S5130 Homemaker service, nos; per 15 minutes 7.07
per 15 minutes
S9470 Nutritional counseling, dietitian visit 63.61
per hour
T2003 Non-emergency transportation; encounter/trip 100.00
per client month
T2022 Case management, per month 363.23
per client month
T2025 Waiver services; not otherwise specified (nos) 246.91
per client month

An Erroneous Payment Correction will be implemented to reprocess affected claims. No action is required of providers. These rates are exclusive for MCWP.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program aids (2, 3, 12–16, 18, 19, 21, 24); aids bil cd (1)
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2. New Modifier ZB Required for HCPCS Code Q5102

Effective retroactively for dates of service on or after July 1, 2016, modifier ZB (Pfizer/Hospira) is required when billing for Inflectra with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZB was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZB (anesthesia [emergency services, healthy patient]) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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3. New Modifier ZC Required for Billing HCPCS Code Q5102

Effective retroactively for dates of service on or after July 24, 2017, modifier ZC (Merck/Samsung Bioepis) is required when billing for Renflexis with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZC was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZC (anesthesia complicated by extracorporeal circulation) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

The new modifier ZC will be available for use January 1, 2018. To avoid claim denials, providers should submit claims for Q5102 with modifier ZC on or after January 1, 2018. Claims submitted for Q5102 without modifier ZC will continue to be accepted.

An Erroneous Payment Correction (EPC) will be generated to accurately adjudicate claims submitted with the CMS modifier ZC with dates of service on or after July 24, 2017. No action is required of providers.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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4. Coming Soon: Online PDF RAD and Medi-Cal Financial Summary

Providers will soon be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions Services tab.

Note:  To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

Benefits of PDF RAD
There will be many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments will be made via PDF RADs. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for additional information.

Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246 form). The form, which is expected to be modified in December, is located on the Forms page of the Medi-Cal website (www.medi-cal.ca.gov). The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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5. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective October 1, 2017
NDC Labeler Code Contracting Company's Name
69809 HLS THERAPEUTICS (USA), INC.
69865 DEPO NF SUB, LLC
70437 PUMA BIOTECHNOLOGY, INC.
70510 MITSUBISHI TANABE PHARMA AMERICA, INC.
70655 RENAISSANCE LAKEWOOD, LLC.
71090 STRONGBRIDGE U.S. INC.
   
Terminations, effective October 1, 2017
NDC Labeler Code Contracting Company's Name
11528 CENTRIX PHARMACEUTICAL, INC.
42546 PRUGEN, INC.
69437 CANTON LABORATORIES, LLC.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (6, 8, 18, 19)
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6. RTD Generation to be Discontinued in Multiple Phases

The Department of Health Care Services (DHCS) will be phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1) over the next 12 months. The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. 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.

The implementation of each RTD phase-out period will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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