Medi-Cal Update
Clinics and Hospitals | June 2011 | Bulletin 441Print Medi-Cal Update
The 2011 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are listed below. Only those codes representing current or future Medi-Cal benefits are included in the list of additions. Medi-Cal will implement the code additions, changes and deletions for dates of service on or after September 1, 2011. Please refer to the 2011 CPT-4 and HCPCS Level II code books for complete descriptions of these codes. Specific policy, billing information and manual replacement pages reflecting these changes will be released in a future Medi-Cal Update.
CPT-4 Code Additions
Lab| 82930, 83861, 85598, 86481, 86902, 87501 – 87503, 87906, 88120, 88121, 88177, 88363, 88749 |
| 91013, 92132 – 92134, 92227, 92228, 93451 – 93464, 93563 – 93568, 96446 |
| 92132 – 92134, 92227, 92228 |
| 11045 – 11047, 76881, 76882 |
| 76881 – 76882 |
| 11045 – 11047, 22551, 22552, 29914 – 29916, 31295 – 31297, 31634, 33620 – 33622, 37220 – 37235, 38900, 43283, 43327, 43328, 43332 – 43338, 43753 – 43757, 49327, 49412, 49418, 53860, 57156, 61781 – 61783, 64568 – 64570, 64611, 65778, 65779 |
HCPCS Level II Code Additions
Chemotherapy| C9276, J9302, J9307, J9315, J9351 |
| G0432, G0433, G0435 |
| C9274, C9275, C9279, J0171, J0558, J0561, J0597, J0638, J1290, J1826, J2358, J2426, J3095, J3262, J7196, J7309, S0148 |
| Q4117 – Q4121 |
| Q4117 – Q4121 |
CPT-4 Code Changes
Anesthesia| 00100, 00102 – 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214 – 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528 – 00530, 00532, 00534, 00537, 00539, 00540 – 00542, 00546, 00548, 00550, 00560, 00561, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920 – 00922, 00924, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930 – 01933, 01935, 01936, 01951 – 01953, 01958, 01960 – 01963, 01965 – 01967, 01991, 01992 |
| 96401, 96405, 96409, 96411, 96413, 96413, 96413, 96415, 96420, 96425, 96440, 96450, 96521, 96549 |
| 90281, 90283, 90284, 90288, 90291, 90371, 90375, 90376, 90378, 90384 – 90386, 90389, 90393, 90396, 90470, 90472, 90476, 90477, 90581, 90585, 90586, 90632 – 90634, 90636, 90644 – 90650, 90657, 90658, 90660, 90662, 90663, 90665, 90669, 90670, 90675, 90676, 90680, 90690 – 90693, 90698, 90700 – 90708, 90710, 90713, 90716 – 90721, 90725, 90727, 90733 – 90736, 90740, 90743, 90746 – 90748 |
| 80100, 80101, 80103, 80156, 80157, 80164, 80185, 80186, 80299, 81000, 81001, 81003, 81020, 81050, 82016, 82017, 82043 – 82045, 82103 – 82106, 82120, 82127, 82128, 82131, 82135, 82136, 82139, 82339, 82240, 82247, 82248, 82270 – 82272, 82274, 82306, 82355, 82360, 82373 – 82376, 82382 – 82384, 82438, 82465, 82480, 82482, 82485, 82491, 82492, 82530, 82541, 82542, 82553, 82554, 82652, 82656, 82658, 82705, 82710, 82747, 82784, 82787, 82803, 82805, 82810, 82926, 82928, 82947, 82952, 82979, 83003, 83009, 83010, 83013, 83018, 83026, 83030, 83033, 83037, 83070, 83071, 83500, 83516, 83518, 83593, 83630, 83661 – 83664, 83700, 83701, 83704, 83876, 83883, 83898, 89908, 83909, 83913, 83918, 83919, 83921, 83950, 83951, 84061, 84152 – 84157, 84160, 84163, 84165, 84182, 84238, 84375 – 84378, 84431, 84480, 84484, 84512, 84704, 85027, 85032, 85378, 85379, 85380, 85396, 85441, 85445, 85460, 85461, 85597, 85613, 85651, 85652, 85670, 85675, 85730, 85732, 86000, 86060, 86063, 86141, 86156, 86157, 86160, 86162, 86171, 86215, 86226, 86255, 86256, 86294, 86300, 86301, 86304, 86316, 86317, 86318, 86334, 86355, 86357, 86359 – 86361, 86367, 86382, 86431, 86480, 86485, 86486, 86590, 86645, 86692, 86703 – 86705, 86708, 86709, 86778, 86788, 86804, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86880, 86885, 86886, 86891, 86900, 86901, 86903 – 86906, 86910, 86911, 86920 – 86923, 86927, 86940, 86975 – 86978, 87001, 87003, 87045, 87046, 87070, 87075, 87076, 87106, 87107, 87143, 87147, 87150, 87158, 87176, 87181, 87184 – 87188, 87190, 87197, 87205 – 87210, 87230, 87250, 87252 – 87254, 87260, 87265, 87267, 87269, 87270, 87272, 87274 – 87276, 87278 – 87281, 87283, 87285, 87290, 87299, 87300, 87301, 87305, 87320, 87324, 87327 – 87329, 87332, 87335 – 87341, 87350, 87380, 87385, 87390, 87391, 87400, 87420, 87427, 87430, 87449 – 87451, 87470 – 87472, 87475 – 87477, 87480 – 87482, 87485 – 87487, 87490 – 87492, 87495 –87498, 87500, 87510 – 87512, 87515 – 87517, 87520 – 57542, 87550 – 87552, 87555 – 87557, 87560 – 87562, 87580 – 87582, 87590 – 87592, 87620 – 87622, 87640, 87641, 87650 – 87653, 87660, 87797 –87801, 87900 – 87904, 88000, 88005, 88007, 88012, 88014, 88016, 88020, 88025, 88027 – 88029, 88104, 88106, 88107, 88108, 88112, 88141, 88142, 88147, 88148, 88150, 88152 – 88155, 88160 – 88162, 88164 – 88167, 88172 – 88174, 88184, 88185, 88187 – 88189, 88230, 88233, 88235, 88237, 88239, 88245, 88248, 88249, 88261 –88264, 88267, 88269, 88271 – 88275, 88285, 88289, 88300, 88314, 88331 – 88334, 88355 – 88356, 88358, 88367, 88368, 88371, 88380, 88381, 88385 – 88388, 89055, 89060, 89258 – 89261, 89290, 89291, 89321, 89322, 89330, 89342 – 89344, 89346, 89352 – 89354, 89356 |
| 90804 – 90819, 90821 – 90824, 90826 – 90829, 90901, 90935, 90937, 90945, 90947, 90951 – 90957, 90959 – 90968, 90970, 90989, 90993, 91010, 92002, 92004, 92225, 92226, 92551 – 92553, 92556, 92560, 92561, 92565, 92570, 92577, 92585, 92586, 92590 – 92595, 92607, 92620, 92621, 92960, 92961, 92970, 92971, 92974, 92975, 92977 – 92979, 92997, 92998, 93000, 93005, 93041, 93042, 93224 – 93229, 93268, 93270 – 93272, 93279 – 93284, 93306 – 93308, 93320, 93321, 93530 – 93533, 93609, 93613, 93623, 93631, 93701, 93750, 93890, 93892, 93893, 93922, 93923, 93924, 94002, 94003, 94011 – 94013, 94644, 94645, 94660, 94662, 94680, 94681, 94772, 94774 – 94777, 95024, 95115, 95120, 95125, 95130 – 95132, 95134, 95250, 95251, 95807, 95808, 95810, 95812, 95813, 95816, 95819, 95822, 95824, 95827, 95831 – 95834, 95857, 95860, 95861, 95863, 95864, 95866, 95869, 95870, 95872, 95956, 95961, 95962, 95965 – 95967, 95970 – 95975, 95980, 95992, 96000, 96040, 96110, 96111, 96150 – 96154, 96360, 96361, 96365, 96369 – 96374, 96376, 96567, 96570, 96571, 96913, 96920 – 96922, 97024, 97597, 97598, 97605, 97606, 97802 – 97804, 98960 – 98962, 99051, 99053, 99143, 99170, 99201 – 99205, 99211 – 99215, 99218 – 99220, 99291, 99292, 99304 – 99310, 99341 – 99345, 99347 – 99350, 99354 – 99357, 99363, 99364, 99381 – 99386, 99387, 99391 – 99396, 99401 – 99404, 99408, 99409, 99411, 99412, 99460 – 99462, 99468, 99469, 99471, 99472, 99475, 99476, 99478, 99500 – 99503, 99505 – 99507, 99510, 99511, 99601, 99602, 99605 – 99607 |
| 92002, 92004, 92225 |
| 90283 – 90284 |
| 70240, 71275, 70336, 70371, 70496, 70498, 72159, 72255, 72265, 72270, 73092, 73225, 73542, 73560, 73562, 73564, 73592, 74022, 74185, 74220, 74230, 74240, 74241, 74245, 74261 – 74263, 74290, 74291, 74355, 74360, 74363, 74420, 74425, 74430, 74440, 74450, 74455, 74474, 74480, 74485, 74740, 74742, 75565, 75573, 75630, 75650, 75658, 75660, 75662, 75665, 75671, 75676, 75680, 75685, 75705, 75710, 75716, 75722, 75724, 75726, 75731, 75733, 75736, 75743, 75746, 75756, 75774, 75801, 75803, 75805, 75807, 75809 – 75810, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75894, 75896, 75940, 75954 – 75962, 75964, 75968, 76001, 76010, 76098, 76510 – 76514, 76645, 76800 – 76802, 76805, 76810 – 76817, 76830, 76831, 76856 – 76857, 76870, 76872, 76873, 76885, 76886, 76930, 76937, 76940, 76945, 76948, 76998, 77003, 77032, 77055 – 77059, 77073 – 77080, 77082, 77084, 77301, 77371, 77372, 77418, 77422, 77423, 77427, 77520, 77522, 77523, 77525, 77785, 77786, 78000, 78001, 78007, 78018, 78102 – 78104, 78110, 78111, 78120, 78121, 78190, 78268, 78271, 78272, 78300, 78305, 78306, 78315, 78350, 78351, 78451 – 78454, 78458, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78586, 78587, 78591, 78593, 78594, 78700, 78800 – 78802, 78804 – 78806, 78811 – 78816, 79005, 79101, 79200, 79300, 79440 |
| 10180, 11010 – 11012, 11042 – 11044, 11056, 11057, 11100, 11101, 11450, 11451, 11462, 11463, 11470, 11471, 11720, 11721, 11732, 11755, 11765, 12054, 15002 – 15005, 15100, 15101, 15130, 15136, 15155, 15175, 15176, 15200, 15300, 15335, 15360, 15400, 15420, 15732, 15734, 15736, 15738, 15757, 15758, 15786 – 15789, 15792, 15793, 15819 ,15845, 16020, 16025, 16030, 16035, 16036, 17003, 17110, 17111, 17250, 17311, 17313 – 17315, 19101, 19105, 19125, 19126, 19290, 19291, 19295, 19303 – 19307, 20005, 20100 – 20103, 20206, 20220, 20225, 20240, 20245, 20526, 20552, 20553, 20600, 20605, 20610, 20660, 20664, 20802, 20805, 20808, 20816, 20822, 20824, 20827, 20838, 20930, 20931, 20950, 20955 – 20957, 20962, 20969, 20970, 20972, 20973, 20982, 21012, 21014, 21016, 21025, 21031, 21032, 21116, 21125, 21127, 21141 – 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21270, 21275, 21552, 21554, 21558, 21931, 21933, 21936, 22010, 22015, 22101, 22102, 22112, 22114, 22206 – 22208, 22216, 22226, 22315, 22523 – 22527, 22534, 22614, 22632, 22818, 22819, 22851, 22901, 23120, 23130, 23395, 23410, 23412, 24071, 24332, 24357, 24358, 25073, 25078, 25394, 25830, 26135, 26140, 26145, 26170, 26235, 26236, 26415, 26553, 26554, 26720, 26725, 26727, 26735, 26740, 26742, 26746, 26750, 26755, 26756, 26765, 26861, 27049, 27065 – 27067, 27070, 27071, 27323 – 27326, 27330, 27337, 27339, 27360, 27364, 27427 – 27429, 27616, 27632, 27634, 27658, 27659, 27664, 27665, 27703, 27870, 28041, 28055, 28060, 28272, 28450, 28455, 28465, 28890, 29505, 29805, 29860 – 29863, 29866 – 29868, 29870, 29893, 29900 – 29902, 30801, 30915, 30920, 30930, 31000, 31002, 31020, 31030, 31032, 31050, 31231, 31233, 31235, 31237 – 31240, 31267, 31276, 31287, 31288, 31290 – 31294, 31320, 31511, 31520, 31561, 31577, 31628, 31629, 31631, 31632, 31636 – 31638, 31641, 31645, 31646, 31656, 31730, 32200, 32201, 32405, 32601 – 32606, 32650 – 32665, 32851, 32853, 32855, 32856, 32998, 33202, 33203, 33218, 33220, 33222, 33244, 33254 – 33258, 33265, 33266, 33401, 33403, 33411, 33415, 33463, 33464, 33471, 33475, 33496, 33506, 33507, 33510 – 33519, 33521 – 33523, 33530, 33533 – 33536, 33548, 33615, 33860, 33863, 33864, 33883, 33884, 33886, 33926, 33935, 34501, 34812, 34820, 34825, 34826, 34833, 34834, 34900, 35002, 35013, 35022, 35082, 35092, 35103, 35112, 35122, 35132, 35142, 35390, 35471, 35526, 35623, 35626, 35700, 35701, 35721, 35901, 35903, 35905, 35907, 36440, 36450, 36460, 36468, 36469, 36475, 36476, 36478, 36481, 36500, 36510, 36515, 36516, 36598, 36620, 36625, 36640, 36660, 36680, 36818, 36819, 36832, 36838, 37195, 37205 – 37208, 37215, 37216, 37765, 37788, 38100, 38101, 38102, 38102, 38120, 38129, 38300, 38305, 38500, 38505, 38510, 38520, 38525, 38530, 38542, 38550, 38555, 38562, 38564, 38570 – 38572, 38589, 38700, 38720, 38724, 39560, 39561, 40804, 40805, 41145, 41150, 41153, 41155, 41520, 41805, 41806, 41820, 42104, 42106, 42107, 42145, 42280, 42281, 42953, 43202, 43220, 43226 – 43228, 43234, 43235, 43237, 43239, 43249, 43279, 43280, 43289, 43330, 43331, 43350 – 43352, 43496, 43605, 43631 – 43635, 43647, 43651 – 43653, 43659, 43775, 43842, 43881, 43886 – 43888, 44126 – 44128, 44132, 44133, 44135, 44136, 44180, 44186 – 44188, 44202, 44203, 44213, 44227, 44238, 44386, 44393, 44500, 44602 – 44604, 44680, 44900, 44901, 44970, 44979, 45190, 45381, 45395, 45397, 45499, 45990, 46250, 46260, 46608, 46610, 46612, 46614, 46900, 46910, 46916, 46917, 46924, 47001, 47010, 47011, 47140 – 47145, 47379, 47480, 47490, 47510, 47579, 47801, 48001, 48100, 48102, 48400, 48556, 49040, 49041, 49060, 49061, 49080, 49180, 49220, 49321, 49322, 49324, 49329, 49402, 49419, 49421, 49422, 49424, 49427, 49492, 49495, 49496, 49500, 49501, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49659, 49904 – 49906, 50020, 50021, 50220, 50225, 50230, 50250, 50320, 50382, 50384, 50542, 50544, 50549, 51703, 51741, 51999, 52001, 52282, 52325, 52327, 52344, 53400, 53405, 53420, 53425, 53500, 54050, 54055, 54056, 54057, 54065, 54111, 54112, 54160, 54411, 54417, 54522, 54690, 54692, 54699, 55300, 55559, 55860, 55866, 55875, 55876, 55970, 55980, 56501, 57022, 57023, 57061, 57065, 57106, 57107, 57110 – 57112, 57155, 57282 – 57285, 57296, 57308, 57423, 57425, 57460, 57461, 57531, 57556, 58291 – 58294, 58353, 58541, 58546, 58553, 58555, 58558 – 58563, 58565, 58570, 58572, 58578, 58660 – 58662, 58670 – 58673, 58679, 58740, 58820, 58822, 58823, 58825, 58953, 58956, 59000, 59001, 59012, 59076, 59898, 60659, 61210, 61570, 61580 – 61583, 61586, 61609 – 61613, 61615, 61616, 61624, 61626, 61640, 61697, 61698, 61700, 61796 – 61799, 61864, 61868, 62267, 62269, 62270, 62318, 63040, 63042 – 63044, 63077, 63078, 63620, 63621, 64400, 64402, 64405, 64408, 64412, 64413, 64415 – 64418, 64420, 64421, 64425, 64430, 64435, 64445 – 64450, 64455, 64479, 64480, 64483, 64484, 64505, 64508, 64510, 64517, 64520, 64530, 64575, 64612 – 64614, 64632, 64708, 64712 – 64714, 64744, 64885, 64886, 64890 – 64893, 64895 – 64898, 65756, 65780 – 65782, 66700, 66720, 66740, 66761, 66820, 66982 – 66984, 67031, 67113, 67346, 67415, 68371, 68505, 69110, 69801, 69802 |
HCPCS Level II Code Changes
Chemotherapy| J9060 |
| G0431 |
| A4399, A5112, A6011, A6248, A6260 – A6262, A6530, A6533 – A6541, A6544, A6545, A6549, A7013, B4034 – B4036 |
| G0151 – G0154, G8427, G8428, G8440, G8441, G8447, G8448, G8508, G8509, J0598 |
| J0598 |
| Q0499, Q4101 – Q4108, Q4110 – Q4113, Q4115, Q4116 |
CPT-4 Code Deletions
Immunizations| 90465 – 90468 |
| 82926, 82928, 86903, 89100, 89105, 89130, 89132, 89135, 89136, 89140, 89141, 89225, 89235 |
| 11040, 11041, 91000, 91011, 91012, 91052, 91055, 91105, 91123, 93012, 93014, 93230, 93231 – 93233, 93235 – 93237, 93501, 93508, 93510, 93511, 93514, 93524, 93526 – 93529, 93539 – 93545, 93555, 93556, 96445 |
| 92135 |
| 75992 – 75996, 76150, 76350, 76880 |
| 20000, 33861, 35454, 35456, 35473, 35474, 35459, 35470, 35480 – 35485, 35490 – 35495, 39502, 39520, 39530, 39531, 43324, 43326, 43600, 49420, 61795, 64573 |
HCPCS Level II Code Deletions
Chemotherapy| C9259, C9265, J9062, J9110, J9140, J9290, J9291, J9350, S0146, |
| S3905 |
| Q1003 |
| C9255, C9256, C9258, C9264, C9265, J0128, J0170, J0559, J0560, J0570, J0580, J0704, J0970, J1390, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1785, J1825, J2321, J2322, S0161, S0196 |
| S2270 |
| S2344 |
| Q4109 |
Modifier Additions
AY, AZ, CS, DA, GU, GX, NB, PT
Retroactively effective for dates of service on and after January 1, 2010, the list of reimbursable diagnoses for treatment with docetaxel (taxotere) (HCPCS codes J9171 and X7638) is expanded to include ICD-9-CM 195.0 (malignant neoplasm of head, face and neck). An Erroneous Payment Correction (EPC) will be automatically processed for denied claims. Providers do not need to rebill.
Effective for dates of service on or after May 1, 2011, the following ICD-9-CM codes are required for reimbursement of HCPCS code J9171 (injection, docetaxel, 1 mg):
| ICD-9-CM Code | Description |
| 174.0 – 175.9 | Breast cancer |
| 150.0 – 151.0 235.5 |
Esophageal cancer |
| 151.0 – 151.9 235.2 |
Gastric cancer |
| 140.0 – 141.9 143.0 – 149.9 161.0 – 161.9 173.0 195.0 235.1 235.6 |
Head and neck cancer |
| 162.0 – 162.9 | Non-small cell lung cancer |
| 199.0 199.1 |
Occult primary |
| 158.8 183.0 – 183.9 |
Ovarian cancer |
| 185 | Prostate cancer |
| 162.0 – 162.9 197.0 197.7 198.3 198.5 198.7 209.30 |
Small cell lung cancer |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug a-d (13–14) |
Effective retroactively for dates of service on or after January 1, 2011, the Department of Health Care Services is implementing the following new CPT-4 codes for computed tomography (CT):
| CPT-4 Code | Description | |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | |
| 71477 | with contrast material(s) | |
| 74178 | without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions | |
These codes must be used when claiming CT for both the abdomen and pelvis on the same date of service. All other CT policy applies to these codes. The codes are split-billable and require a modifier.
Providers are reminded: Claims denied with abdomen CT codes 74150, 74160 and 74170 or pelvis CT codes 72192, 72193 and 72194 should be resubmitted to include codes 74176, 74177 and/or 74178, as appropriate. When claiming CT abdomen and pelvis codes 74176 – 74178, do not claim codes 72192 – 72194 or 74150 – 74170. Claims resubmitted for these codes, prior to November 1, 2011 will not be reduced for late submission.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
General Medicine Obstetrics |
radi dia (1) |
Providers are reminded that the price listed on the Medi-Cal Rates page of the Medi-Cal website for each Physician Administered Drug includes the one-time administration fee of $4.46 for injections. Since the administration fee is paid only once for each drug administered, subsequent units claimed must have the administration fee subtracted from the published rate.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals Chronic Dialysis Clinics Medical Services Pharmacy Rehabilitation Clinics |
inject an over (1) |
| Clinics and Hospitals General Medicine |
chemo an over (1) |
Effective for dates of service on or after July 1, 2011, CPT-4 codes 90281 (immune globulin, human, for intramuscular use) and 90283 (immune globulin, human, for intravenous use) will be replaced with corresponding immune globulin HCPCS codes for reimbursement.
An approved Treatment Authorization Request (TAR) is required for reimbursement. Claims submitted with HCPCS codes J1460, J1560, J1566 or J1599 must include an invoice for manual pricing or the claim will be denied.
| Deleted CPT-4 Codes | Replacement HCPCS Codes | |
| 90281 (intramuscular) |
J1460 J1559 J1560 J1562 |
Gamma globulin, 1 cc Immune globulin, (Hizentra), 100 mg Gamma globulin, over 10 cc Immune globulin, (Vivaglobin), 100 mg |
| 90283 (intravenous) |
C9270 J1459 J1561 J1566 J1568 J1569 J1572 J1599 |
Immune globulin, (Gammaplex), non-lyophilized (e.g. liquid), 500 mg Immune globulin, (Privigen), non-lyophilized (e.g. liquid), 500 mg Immune globulin, (Gamunex), non-lyophilized (e.g. liquid), 500 mg Immune globulin, (Gammaplex), lyophilized (e.g. powder), not otherwise specified, 500 mg Immune globulin, (Octagam), non-lyophilized (e.g. liquid), 500 mg Immune globulin, (Gammagard Liquid), non-lyophilized (e.g. liquid), 500 mg Immune globulin, (flebogamma/flebogamma DIF), non-lyophilized (e.g. liquid), 500 mg Immune globulin, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
General Medicine Obstetrics |
immun (1); inject cd list (8–9); inject drug a-l (35–36); non ph (10, 18); tar and non cd9 (1) |
| Rehabilitation Clinics | immun (1); inject cd list (8–9); inject drug a-l (35–36); non ph (10, 18) |
| Chronic Dialysis Clinics Pharmacy |
immun (1); inject cd list (8–9); inject drug a-l (35–36) |
| Inpatient Services | tar and non cd9 (1) |
Effective June 1, 2011, Incobotulinum Toxin Type A has been added to the California Children’s Services/Genetically Handicapped Persons Program (CCS/GHPP) list of drugs and nutritional products that are not included in a physician’s Service Code Groupings (SCGs) and require a separate SAR.
The following codes will be added/end-dated to/from the CCS SCGs with an effective date of June 1, 2011, or September 1, 2011:
Added Code(s)| Effective Date | Code | SCGs |
| June 1, 2011 | HCPCS codes: C9280, G0434, J1460 and J1560 | 01, 02, 03 and 07 |
| June 1, 2011 | HCPCS codes: C9270, J1459, J1559, J1561, J1562, J1566, J1568, J1569, J1572, J1599 and Q2040 | 51 |
| September 1, 2011 | HCPCS codes: C9274 – C9276, G0432, G0433, G0435, J0597, J0638, J0960, J1290, J1826, J2358, J2426, J3095, J3262, J7309, J7335, J9302, J9307, J9315, J9351 and S0148 and CPT-4 codes: 31634, 43753 – 43757, 53860, 74176 – 74178, 82930, 83861, 85598, 86481, 86902, 87501 – 87503, 88120, 88121, 88177, 88363, 88749, 91013, 92132 – 92134, 92227, 92228 and 96446 | 01, 02, 03 and 07 |
| September 1, 2011 | HCPCS codes: C9279, J0558 and J0561 and CPT-4 codes: 11045 – 11047, 76881, 76882, 87906, 97597 and 97598, | 01, 02, 03, 07 and 12 |
| September 1, 2011 | CPT-4 codes: 49418, 93451 – 93464 and 93563 – 93568 |
02 and 03 |
| September 1, 2011 | CPT-4 codes: 65778 and 65779 | 10 |
| September 1, 2011 | HCPCS codes: Q4100 – Q4114 and Q4117 – Q4121 |
12 |
| September 1, 2011 | HCPCS code: J7196 and CPT-4 code: 64568 | 51 |
| Effective Date | Code | SCGs |
| June 1, 2011 | HCPCS code: G0430 and CPT-4 codes: 80100, 80101 and 90281 | 01, 02, 03 and 07 |
| June 1, 2011 | CPT-4 code 90283 | 51 |
| September 1, 2011 | HCPCS codes: C9255, C9259, C9264, J9062, J9350 and CPT-4 codes: 75992 – 75996, 76150, 76350, 76880, 82926, 82928, 89100, 89105, 89130, 89132, 89135, 89136, 89140, 89141, 89225, 89235, 91000, 91011, 91012, 91052, 91055, 91105, 91123, 92135, 93012, 93014, 93230 – 93233, 93235 – 93237 and 96445 | 01, 02, 03 and 07 |
| September 1, 2011 | HCPCS codes: J0559, J0560, J0570 and J0580 and CPT-4 codes: 11040, 11041 and 86903 | 01, 02, 03, 07 and 12 |
| September 1, 2011 | HCPCS codes 43600, 49420, 93501, 93508, 93510, 93511, 93514, 93524, 93526 – 93529, 93539 – 93545, 93555 and 93556 | 02 and 03 |
| September 1, 2011 | HCPCS code 20000 | 12 |
| September 1, 2011 | HCPCS code 64573 | 51 |
This list contains codes that are not yet effective. Claims billed with codes not yet effective will be denied.
Reminder:SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Audiology and Hearing Aids Chronic Dialysis Clinics Clinics and Hospitals Durable Medical Equipment and Medical Supplies General Medicine Home Health Agencies/Home and Community-Based Services Inpatient Services Medical Transportation Local Educational Agency Obstetrics Orthotics and Prosthetics Pharmacy Psychological Services Rehabilitation Clinics Therapies Vision Care |
cal child sar (7); cal child ser (1–2, 6–17, 23–28); genetic (8) |
Effective April 1, 2011 through March 31, 2012, the Presumptive Eligibility Program is to use the following 2011 Federal Poverty Level (FPL) chart for determining income eligibility. Providers should disregard all previous FPL charts.
| 200 PERCENT OF POVERTY LEVEL | ||
| Number of Persons | Monthly Income | Annual Income |
| 2 | $2,452 | $29,420 |
| 3 | $3,089 | $37,060 |
| 4 | $3,725 | $44,700 |
| 5 | $4,362 | $52,320 |
| 6 | $4,999 | $59,980 |
| 7 | $5,635 | $67,620 |
| 8 | $6,272 | $75,260 |
| 9 | $6,910 | $82,900 |
| 10 | $7,548 | $90,540 |
| For each additional member, add | $638 | $7,640 |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
General Medicine Obstetrics Pharmacy |
presum (6) |
Once-in-a-lifetime HCPCS code S3854 (gene expression profiling panel for use in the management of breast cancer) is reimbursable more than once-in-a-lifetime for the same recipient if the claim documents that the recipient has a new breast cancer occurrence that fits the following medical-necessity criteria:
Failure to document that all six of the above criteria have been met will result in the claim being denied. HCPCS Level II laboratory code S3854 must be billed with ICD-9-CM diagnosis codes 174.0 – 174.9 (malignant neoplasm of female breast). This code is not split-billable, and must not be billed with modifiers 26, TC, or ZS.
For guidelines refer to “Gene Expression Profiling: HCPCS Code S3854” in the Part 2 provider manual section, Pathology: Billing and Modifiers.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
General Medicine Obstetrics |
once (1) |
Effective for dates of service on or after August 1, 2011, frequency restrictions for laboratory procedure claims will be overridden when either the primary or secondary diagnoses on the claim is one of the following codes:
Effective for dates of service on or after July 1, 2011, Physician Administered Drug (PAD) local codes X6462 (lidocaine HCl-20%, 200 mg), X6464 (lidocaine HCl 10%, 10 mg/ml), and X6494 (lidocaine HCl, 4 %, 40 mg/ml) will be converted to HCPCS code J2001 (lidocaine injection for intravenous infusion, 10 mg). The following 13 local codes for lidocaine hydrochloride (HCl) will also be end-dated effective July 1, 2011:
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
Chronic Dialysis Clinics Rehabilitation Clinics General Medicine Obstetrics Pharmacy |
inject cd list (10–11) |
Medi-Cal providers seeking enrollment in the Family PACT (Planning, Access, Care and Treatment) Program are required to attend a Provider Orientation and Update Session. Dates for upcoming sessions are listed below. Registration opens at 8 a.m., with Session I beginning promptly at 8:30 a.m.
Individual and group providers wishing to enroll must send a physician-owner to the session. Non-profit and government clinics seeking to enroll must send their medical director, physician or nurse practitioner who is responsible for oversight of medical services rendered at the service site where the provider wants to enroll.
Office staff members, such as clinic managers, billing supervisors and client eligibility enrollment supervisors, are encouraged to attend. However, these staff members are not eligible to receive a Certificate of Attendance. Enrolled clinicians and staff are encouraged to attend to remain current with program policies and services.
Session Format
Family PACT has created a new session format, which offers an option for currently enrolled providers and staff to attend only the afternoon update session, along with either the clinical session or the billing and coding session.
Session I – Overview of the Family PACT Program:
| Start Time | 8:30 a.m. to 2 p.m. |
| Instructions | Attendance at this presentation is mandatory for clinician providers wishing to enroll in Family PACT and is recommended for other staff who are new to the program or need a refresher. |
Note: The afternoon sessions will run concurrently from 2 p.m. to 4 p.m.
Session II – Clinical Practice Alerts:
| Start Time | 2 p.m. to 4 p.m. |
| Instructions | Clinicians in attendance who wish to become Family PACT providers must also attend this session. Free continuing education (CE) credit is available for Session II. Providers must bring their medical license number if requesting CE credit; a continuing education request form will be available during onsite registration. Other interested clinical staff are welcome to attend and may request free CE credit for this session. |
Session III – Tips for Successful Family PACT Administration:
| Start Time | 2 p.m. to 4 p.m. |
| Instructions | Administrators and billers interested in Family PACT Program administration and billing information may attend. |
Please note the upcoming Provider Orientation and Update Sessions below.
| Los Angeles July 7, 2011 8:30 a.m. – 4 p.m. Radisson LAX 6225 West Century Boulevard Los Angeles, CA 90045 (310) 670-9000 |
San Luis Obispo July 21, 2011 8:30 a.m. – 4 p.m. Embassy Suites 333 Madonna Road San Luis Obispo, CA 93405 (805) 549-0800 |
Oakland August 16, 2011 8:30 a.m. – 4 p.m. California Endowment 1111 Broadway, 7th Floor Oakland, CA 94607 (510) 271-4333 |
Anaheim August 23, 2011 8:30 a.m. – 4 p.m. Embassy Suites 11767 Harbor Boulevard Garden Grove, CA 92840 (714) 539-3300 |
| Bakersfield September 29, 2011 8:30 a.m. – 4 p.m. Marriott 801 Truxtun Avenue Bakersfield, CA 93301 (661) 323-1900 ext 1001 |
Sacramento October 18, 2011 8:30 a.m. – 4 p.m. Four Points by Sheraton 4900 Duckhorn Drive Sacramento, CA 95834 (916) 263-9000 |
Palm Springs November 17, 2011 8:30 a.m. – 4 p.m. Hyatt Regency Suites 285 North Palm Canyon Drive Palm Springs, CA 92262 (760) 322-9000 |
Ventura December 6, 2011 8:30 a.m. – 4 p.m. Ventura Beach Marriott 2055 E. Harbor Boulevard Ventura, CA 93001 (805) 643-6000 |
For a map and directions to these locations, providers can go to the Family PACT website and click “Directions and Map of Location” for the appropriate session location.
Registration
To register for an orientation and update session, providers should:
Providers with no Internet access may request the registration form by calling 1-877-FAMPACT (1-877-326-7228). Providers must supply the following when registering:
Check-In
Check-in begins at 8 a.m. All orientation sessions start promptly at 8:30 a.m. and end by 4 p.m. At the session, providers must present the following:
Note: Individuals representing a clinic or physician group should use the clinic or group NPI, not an individual NPI or license number.
Certificate of Attendance
Upon completion of the orientation session, each prospective new Family PACT medical provider will receive a Certificate of Attendance. Providers should include the original copy of the Certificate of Attendance when submitting the Family PACT application and agreement forms (available at the session) to Family PACT Provider Enrollment. Providers arriving late or leaving early will not receive a Certificate of Attendance. Currently enrolled Family PACT providers do not receive a certificate.
Contact Information
For more information about the Family PACT Program, please call 1-877-FAMPACT (1-877-326-7228) or visit the Family PACT website.
The Family PACT Program was established in January 1997 to expand access to comprehensive family planning services for low-income California residents.
Effective for dates of service on or after July 1, 2011, chemotherapeutic drug Ifosfamide will convert from HCPCS local code X7584 (ifosfamide, 100 mg) to code J9208 (ifosfamide, 1 gm). The maximum dose for code J9208 is 15 gm; however, a dose in excess of 15 gm is allowed with documentation of body surface area greater than 2 meters 2 or when authorization has been obtained.
Code J9208 is reimbursable to certified nurse midwives, nurse practitioners and physician assistants according to standard Medi-Cal policy.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug e-o (6); inject cd list (9); inject drug m-z (1) |
| Chronic Dialysis Rehabilitation Clinics Obstetrics Pharmacy |
inject cd list (9); inject drug m-z (1) |
Effective for dates of service on or after July 1, 2011, HCPCS code Q2043 (sipuleucel-T [Provenge]) is a new Medi-Cal benefit. One dose of sipuleucel-T is 250 ml. An approved Treatment Authorization Request (TAR) documenting the following is required:
The recommended course of therapy is three complete doses, given at approximately two-week intervals. In controlled clinical trials, the median dosing interval between infusions was two weeks (range one to 15 weeks). The maximum dosing interval has not been established.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug p-z (8–9); inject cd list (16) |
| Chronic Dialysis Rehabilitation Clinics Obstetrics Pharmacy |
inject cd list (16) |
Effective for dates of service on or after July 1, 2011, ICD-9-CM code 995.29 (unspecified adverse effect of other drug, medicinal, and biological substance) will be added to a list of qualifying diagnosis codes for reimbursement of CPT-4 laboratory procedure codes 84702 (gonadotropin, chorionic, quantitative) and 84703 (gonadotropin, chorionic, qualitative).
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals Chronic Dialysis Clinics General Medicine Obstetrics |
path chem (6) |
Some claims submitted for laboratory services were inappropriately paid due to poor positioning of modifiers on the claim. Procedure-required modifiers should be positioned on the claim before NCCI-associated modifiers. For Medi-Cal manual purposes, procedure-required and NCCI-associated modifiers are identified as follows.
Procedure-Required Modifiers
Claims for some Medi-Cal procedures require inclusion of a modifier or the claim will be denied. These are procedure-required modifiers.
NCCI-Associated Modifiers
The Centers for Medicare & Medicaid Services (CMS) has identified a set of national modifiers to facilitate claims processing in cases where there is appropriate reason to override an NCCI edit. These are NCCI-associated modifiers.
Actions Being Taken
Providers need take no action for previously processed claims. Claims will be automatically reprocessed. In addition, special claims handling steps are being initiated to ensure claims process correctly. Also, a new Medi-Cal Part 2 provider manual section, Correct Coding Initiative: National – Claim Preparation has been developed with modifier placement examples, and other manual sections updated, to clarify the importance of modifier order on claims.
NCCI edits were incorporated into the Medi-Cal claims processing system effective March 28, 2011. Efforts were made to anticipate discrepancies between established Medi-Cal edits and NCCI edits but it was understood some differences would be identified only as claims were processed.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Acupuncture Chiropractic Medical Transportation Pharmacy |
cms comp (17) |
| Medical Transportation |
cms comp (17); modif app (1) |
| Audiology and Hearing Aids Durable Medical Equipment and Medical Supplies Orthotics and Prosthetics Therapies |
cms comp (17); correct (4); correct cod (1–3); modif app (1) |
| Psychological Services | cms comp (17); correct (4); correct cod (1–3) |
| Adult Day Health Care Centers Heroin Detoxification Multipurpose Senior Services Program |
correct (4); correct cod (1–3) |
| Local Educational Agency Home Health Agencies/Home and Community-Based Services |
modif app (1) |
| Clinics and Hospitals | correct (4); correct cod (1–3); modif app (1); path molec (1) |
| AIDS Waiver Program Chronic Dialysis Clinics Expanded Access to Primary Care Program Rehabilitation Clinics Vision Care |
correct (4); correct cod (1–3); modif app (1) |
| General Medicine Obstetrics |
cms comp (17); correct (4); correct cod (1–3); modif app (1); path molec (1) |
Effective for dates of service on and after July 1, 2011, the following 10 interim X codes for injectable heparin sodium of varying strengths are terminated. Providers should instead bill this injectable with the national HCPCS codes indicated in the left columns of the following chart.
| National HCPCS Code | Description | Terminated Interim X Codes |
| J1642 | Injection, heparin sodium per 10 units | X6282, X6284 |
| J1644 | Injection, heparin sodium per 1000 units | X6286, X6288, X6296, X6298, X6302, X6304, X6306, X6308 |
The maximum dosage is 6.8 gm. However, a dose in excess of 6.8 gm is allowed with documentation of patient weight more than 136 kg.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject cd list (8–9, 11, 14) |
Effective for dates of service on or after July 1, 2011, all Certified Nurse Practitioner (CNP) specialists will be eligible to enroll and bill as Medi-Cal independent providers. Each CNP must:
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine Obstetrics |
gene coun (5); non ph (5, 12–13) |
| Rehabilitation Clinics |
non ph (5, 12–13) |
Medi-Cal providers now have the opportunity to attend free online seminars taught by eTAR training specialists. Webinars are presented live through the Medi-Cal website. Providers are invited to attend a webinar in the comfort of their office.
Registration
First time webinar attendees must register first here. Once registration is complete, select “Course Catalog” from the menu and select “Calendar View.”
June and August Webinars
June 16, 2011 at 9:30 a.m.: eTAR DME-Mobility Providers
This webinar is designed for eTAR providers who submit DME-Mobility eTARs. All functions of the eTAR application will be discussed.August 3, 2011 at 9:30 a.m.: eTAR
This webinar will discuss every function of the eTAR application.
August 11, 2011 at 1:30 p.m.: eTAR Transportation
This webinar is designed for eTAR providers who submit Non Emergency Medical Transportation (NEMT) eTARs. All functions of the eTAR application will be discussed.
There will also be Q&A sessions during each of the webinars.
Note:These webinars address submitted and updating electronic TAR submissions. Paper TARs cannot be updated using the eTAR systems. To learn more about submitting eTARs, check the eTAR Program page for future seminars and webinars.
Some claims submitted for procedure codes billed with modifier 55 (post-operative management only) were inappropriately denied due to differences between National Correct Coding Initiative (NCCI) edits and established Medi-Cal edits. Providers need take no action. Claims using modifier 55 that were inappropriately denied will be reprocessed.
The discrepancy occurred because Medi-Cal was not aware of the Centers for Medicare & Medicaid Services (CMS) mandate that Medically Unlikely Edits (MUEs) are not to be applied to claims submitted for any procedure code billed with modifier 55.
NCCI edits were incorporated into the Medi-Cal claims processing system effective March 28, 2011. Efforts were made to anticipate discrepancies between established Medi-Cal edits and NCCI edits but it was understood some differences would be identified only as claims were processed.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Audiology and Hearing Aids Durable Medical Equipment and Medical Supplies Orthotics and Prosthetics Psychological Services Therapies Adult Day Health Care Centers AIDS Waiver Program Clinics and Hospitals Chronic Dialysis Clinics Expanded Access to Primary Care Program Heroin Detoxification Multipurpose Senior Services Program Rehabilitation Clinics General Medicine Obstetrics Vision Care |
correct (4) |
Effective for dates of service on or after August 1, 2011, HCPCS Level III Local Code Z6210 (prenatal vitamin – mineral supplement, 300 day supply) will convert to HCPCS Level II National Code S0197 (prenatal vitamins, 30 day supply). The rate for the 30-day supply will be $3.00 and the frequency will be restricted to 10 in nine months, from the same provider. Code S0197 must be billed with the following antepartum ICD-9-CM diagnosis codes: V22.0 – V23.9 and 640.0 – 676.9.
Claims billing for code Z6210 on or after August 1, 2011, will be denied.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine Obstetrics |
preg com lis (2) |
Effective for dates of service on or after July 1, 2011, HCPCS code C9729 (percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements, [with ligamentous resection, discectomy, facetectomy and/or foraminotomy, when performed] any method under indirect image guidance, with the use of an endoscope when performed, single or multiple levels, unilateral or bilateral; lumbar) is a new benefit. The service must be billed “By Report,” requires an invoice and is only payable to the primary surgeon.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
surg nerv (1) |
Retroactively effective for dates of service on or after October 1, 2010, the rate of reimbursement for HCPCS code J9041 (injection, bortezomib) is adjusted up from $40.93 to $44.24 per unit (0.1 mg) to reflect the increase in the average wholesale price (AWP).
Reimbursement for dosages exceeding 35 units requires documentation of body surface area greater than 2.7 meters2, or an approved Treatment Authorization Request (TAR).
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
chemo drug a-d (6) |
Effective for dates of service on and after July 1, 2011, interim code X5656 (chloroquine HCl, 50 mg/ml) is no longer a Medi-Cal benefit. Additionally, the following nine interim X codes are converted to national HCPCS codes as indicated:
| HCPCS Code | Description | Terminated Interim X Codes |
| J0210 | Methyldopate HCl, up to 250 mg | X5540 |
| J0278 | Amikacin sulfate, 100 mg | X5558, X5560, X5562 |
| J0300 | Amobarbital, up to 125 mg | X5566 |
| J0330 | Succinylcholine chloride, up to 20 mg | X5636, X6828, X6830 |
| J0360 | Hydralazine HCl, up to 20 mg | X5648 |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject cd list (2, 4, 9, 12, 16–17) |
Effective for dates of service on or after July 1, 2011, CPT-4 drug testing codes 80100, 80101 and 80104 are not reimbursable despite submission of a Treatment Authorization Request/Service Authorization Request (TAR/SAR). Additionally, HCPCS code G0430 will be placed on terminated status for Medi-Cal.
As of June 1, 2011, the above codes were placed on non-pay status, however the CPT-4 codes were potentially reimbursable with an approved TAR or SAR. HCPCS code G0430 was terminated by the Centers for Medicare & Medicaid Services (CMS) effective December 31, 2010, and is therefore no longer valid for Medi-Cal.
When billing for drug screening, providers must use HCPCS codes G0431 (drug screen, qualitative; multiple drug classes by high complexity method, per patient encounter) and G0434 (drug screen, qualitative; multiple drug classes other than chromatographic method, each patient encounter).
Effective April 1, 2011 through March 31, 2012, the Cancer Detection Programs: Every Woman Counts (CDP: EWC) program is to use the following 2011 Federal Poverty Level (FPL) chart for determining income eligibility. Providers should disregard all previous FPL charts.
| 200% OF POVERTY LEVEL | ||
| Number of Persons | Monthly Income | Annual Income |
| 1 | $1,815 | $21,780 |
| 2 | $2,452 | $29,420 |
| 3 | $3,089 | $37,060 |
| 4 | $3,725 | $44,700 |
| 5 | $4,362 | $52,340 |
| 6 | $4,999 | $59,980 |
| 7 | $5,635 | $67,620 |
| 8 | $6,272 | $75,260 |
| For each additional member, add | $637 | $7,640 |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| General Medicine Obstetrics Clinics and Hospitals |
can detect (8) |
The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.
| Addition, effective April 1, 2011 | |
| NDC Labeler Code | Contracting Company’s Name |
| 51167 | VERTEX PHARMACEUTICALS, INC. |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Pharmacy | drugs cdl p5 (10) |
The following is a list of tips for successfully submitting therapy eTARs. Providers who participate in the eTAR program are encouraged to bookmark this page for future reference.
Attachment Information
When submitting attachments, be sure to include only pertinent documentation that medically justifies why the service is needed, including the doctor’s prescription. The same types of attachments that are required with paper Treatment Authorization Requests (TARs) should be submitted with eTARs by fax or by uploading.
Miscellaneous TAR Information
The Miscellaneous TAR information section of eTAR allows providers to enter additional details and medical justification pertinent to the requested service. Providers may enter up to 500 characters in this section. Brief, detailed medical justification should always be included.
General TAR information
Effective November 1, 2008, providers must use a Medi-Cal registered National Provider Identifier (NPI) on all TARs. If providers use legacy numbers, the TARs may be denied.
If a TAR is submitted billed between two providers, the Rendering Provider # field must be completed with the correct NPI.
Inform the rendering provider the TAR has been submitted with their number in the rendering provider field. This will allow the rendering provider to view the TAR online through TAR Inquiry and avoid duplicate submissions.
When an eTAR needs an extension of time and units, submit a new TAR.
Speech Therapy services rendered in an outpatient setting are limited to a maximum of two services per month, subject to the availability of Medi-Service reservations. Initial and six-month evaluations do not require prior authorization.
The prescription must be submitted in the eTAR attachments. The prescription should include the name, address and telephone number of the prescribing practitioner, the date of prescription, the medical condition necessitating the services, the specific services prescribed (treatments, modalities), the duration of medical necessity for services and the anticipated medical outcome as a result of the therapy.
The supplemental summary of the medical condition or functional limitations must be submitted with the eTAR as an attachment.
Specific dates and length of treatment should be provided if possible. Duration of therapy should be set by the prescriber, but a prescription should extend no longer than six months.
The newly revised eTAR Program Information page gives quick links to:
Remember:Utilize the eTAR application at www.medi-cal.ca.gov or 1-800-541-5555 to inquire on TAR status. For self-paced online training, check out the eTAR tutorials on the Medi-Cal website in the eLearning section.
Based on the results of the recent National Eye Institute (NEI) study “Comparison of AMD Treatments Trials (CATT)”, the Department of Health Care Services (DHCS) has developed additional guidelines for the authorization of ranibizumab (Lucentis™, Genentech) for the treatment of exudative senile macular degeneration. The CATT Study compared the efficacy of intravitreal injections of ranibizumab and bevacizumab (Avastin™, Genentech) and concluded that at one (1) year, bevacizumab and ranibizumab had equivalent effects on visual acuity when administered according to the same schedule. In addition, ranibizumab given as needed with monthly evaluation had effects on vision that were equivalent to those of ranibizumab administered monthly.
Given the results of the CATT Study and California Code of Regulations (CCR), Title 22, Section 51003 (f), which states “Authorization may be granted only for the lowest cost item or service covered by the Medi-Cal program that meets the beneficiary's medical needs,” DHCS expects providers to use bevacizumab rather than ranibizumab in the treatment of exudative senile macular degeneration since the cost of bevacizumab is significantly lower than ranibizumab. DHCS also recognizes that there may be instances or special circumstances when it may be prudent to use ranibizumab rather than bevacizumab. When this occurs, DHCS requires providers to include the following on the Treatment Authorization Requests (TARs) for ranibizumab (HCPCS code J2778: Ranibizumab Injection, 0.1 mg) when prescribed for the treatment of exudative senile macular degeneration:
All other policy for ranibizumab remains unchanged.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine |
ophthal (5) |
Pages updated due to ongoing provider manual revisions:
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