Medi-Cal Update

AIDS Waiver Program | January 2018 | Bulletin 520

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1. 2018 CPT-4/HCPCS Annual Update: Policy Updates

The 2018 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 2018 CPT-4/HCPCS Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

For Specialty Programs, current or future benefits for updated CPT-4 and HCPCS codes are reflected in the following PDF documents:

The code additions, changes and deletions are effective for dates of service on or after February 1, 2018. Please refer to the 2018 CPT-4 and HCPCS Level II code book for complete descriptions of these codes.

HCPCS codes J7210 and J7211 will be effective for dates of service on or after April 1, 2018.

Providers should refer to the HCPCS Annual Update for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids audio (9, 10); cal child ser (1–20, 25, 26, 30–32); tax (9–12)
Adult Day Health Centers audio (9, 10)
CHDP Provider Manual chdp trans (1)
Chronic Dialysis Clinics blood (7); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); path bil (8); vaccine (4, 8)
Clinics and Hospitals allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5–7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 30, 32, 35, 36, 41, 42); preg com los (1); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Durable Medical Equipment cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7); tax (9–12)
Family PACT ben fam (23, 25, 30, 41); ben grid (3, 4, 7, 24); drug (2, 7)
General Medicine allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
cal child ser (1–20, 25, 26, 30–32)
Inpatient Services cal child ser (1–20, 25, 26, 30–32); hyst (4); ster (26); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9)
Obstetrics cal child ser (1–20, 25, 26, 30–32); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); ster (26); surg bil mod (7, 8); surg female (2); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Orthotics and Prosthetics cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); tax (9–12)
Pharmacy blood (7); cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); presum (11, 12, 15, 17, 19); tax (9–12)
Psychological Services cal child ser (1–20, 25, 26, 30–32); psychol (2, 4)
Rehabilitation Clinics audio (9, 10); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); respir (6, 7); vaccine (4, 8)
Therapies audio (9, 10); cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7)
Vision Care cal child ser (1–20, 25, 26, 30–32); medi non cpt (2)
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2. 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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3. Update: Online PDF RAD and Medi-Cal Financial Summary

In early 2018 providers will 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 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 PDF RAD updates.

835 Transactions
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). The form is located on the Forms page of the Medi-Cal website. 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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4. Erroneous Treatment Delays and Denials for HIV PrEP and PEP

The Department of Health Care Services (DHCS) has recently been made aware of incidents of erroneous treatment delays and denials for HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) used to prevent seroconversion to HIV. These incidents have negatively impacted beneficiary health. In most of the identified cases the cause for delay/denial of a service was a basic lack of information/understanding related to the scope of benefits and/or claims processes involved with billing for the service.

For Medi-Cal beneficiaries enrolled in a Managed Care Plan (MCP), PrEP and PEP medications are noncapitated. These medications are billed and reimbursed as Medi-Cal fee-for-service claims for both MCP and fee-for-service beneficiaries. When used as a preventative regimen for people at risk of acquiring HIV (PrEP) or for post-exposure treatment, these medications do not require a Treatment Authorization Request (TAR) as DHCS understands the consequence of delaying or denying access to these life-altering medications.

Many of the delays and denials involve pharmacies in the MCP networks not dispensing PrEP and PEP and pharmacy staff incorrectly informing beneficiaries that PrEP and PEP are not benefits of Medi-Cal. There have also been reports of medical providers misinforming patients that PrEP treatment is not a benefit, therefore refusing to issue a prescription for the medications, and instructing patients to use condoms along with traditional safe sex practices.

DHCS encourages timely access, as delays in access to these medications may have deleterious health effects for beneficiaries, including seroconversion from HIV negative to HIV positive. It is the responsibility of pharmacy providers, medical providers and ancillary staff to be fully informed about the scope of benefits and the proper submission of claims for noncapitated drugs. DHCS requests that all Medi-Cal providers, both MCP and fee-for-service, review the scope of benefits associated with drugs used to prevent the transmission of HIV. DHCS encourages providers to take appropriate actions to ensure that all ancillary staff are equally well informed regarding the scope of benefits and the processes and procedures for providing and billing for the medications when it is medically necessary.

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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 January 1, 2018
NDC Labeler Code Contracting Company's Name
50268 AVPAK
59353 VIFOR (INTERNATIONAL) INC.
60219 AMNEAL PHARMACEUTICALS
70436 SLATE RUN PHARMACEUTICALS, LLC
70709 CYCLE PHARMACEUTICALS, LTD.
70785 IRONWOOD PHARMACEUTICALS, INC.
70801 FLEXION THERAPEUTICS, INC.
70842 MELINTA THERAPEUTICS, INC
71093 ACI HEALTHCARE USA, INC.
75826 WINDER 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 (10, 13, 19, 20)
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6. National Correct Coding Initiative Quarterly Update for January 2018

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are valid for dates of service on or after January 1, 2018.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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7. February 2018 Medi-Cal Provider Seminar

The next Medi-Cal provider seminar is scheduled for February 13 – 14, 2018, at the Ontario Airport Hotel & Conference Center in Ontario, 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 educational information, such as the annual provider seminar and webinar schedule, provider training workbooks, online tutorials, recorded webinars and additional curriculum on the MLP.

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8. 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 for urgent announcements and other updates shortly, after posting 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
  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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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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