Medi-Cal Update

Clinics and Hospitals | May 2017 | Bulletin 512

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2. Providers to Report PPCs Using DHCS Secure Online Portal

Effective June 1, 2017, the Department of Health Care Services (DHCS) will no longer accept paper forms for reporting provider-preventable conditions (PPCs). DHCS began accepting online reporting of PPCs for Medi-Cal on April 3, 2017. The development of secure online submission is in response to provider requests to make PPC reporting easier. This new online process replaces the paper Medi-Cal Provider-Preventable Conditions (PPC) Reporting Form (DHCS 7107). The secure online reporting portal is available on the Instructions for online reporting of PPCs Web page of the DHCS website.

Providers must report health care-acquired conditions (HCACs) when they occur in an acute hospital inpatient setting, and report other provider-preventable conditions (OPPCs) when they occur in any health care setting, according to state law in Welfare and Institutions Code (W&I Code), Section 14131.11, as well as the Code of Federal Regulations (CFR) Title 42, Sections 434, 447 and 438. Providers must report PPCs for any Medi-Cal recipient when any PPC occurs that did not exist prior to the provider initiating treatment, even if the provider will not seek Medi-Cal reimbursement to treat the PPC.

More information about PPC reporting requirements, PPC definitions and mandatory payment adjustments is available on the Medi-Cal Guidance on Reporting Provider-Preventable Conditions Web page of the DHCS website. Providers may email questions about the new PPC process to PPCHCAC@dhcs.ca.gov.

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3. CHDP Phase 2: HIPAA Code Conversion and Claim Form Transition

Effective for dates of service on or after July 1, 2017, the two-digit local procedure codes currently used for Child Health and Disability Prevention (CHDP) program claims are discontinued. The codes will be replaced with national HCPCS procedure codes and modifiers that comply with HIPAA requirements.

The CHDP Confidential Screening and Billing Report (PM 160) claim form will no longer be used to bill for CHDP Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessments, immunizations and ancillary services for dates of service on or after July 1, 2017. For these dates of service, qualified Medi-Cal providers enrolled in the CHDP program must bill CHDP/EPSDT services on a CMS-1500, UB-04 claim form or electronic equivalent. Providers should note the national codes cannot be submitted on the PM 160.

Code Conversion Table: To view the full code conversion and additional instructions, providers may refer to the CHDP Code Conversion Table. Updated manual sections will be released in future CHDP Update and Medi-Cal Update bulletins.

This is Phase 2 of the CHDP transition to national codes and claim submission methods. Phase 1, which was effective February 1, 2017, was for CHDP providers submitting claims for laboratory-only services. To see what was published for Phase 1, providers may refer to the article CHDP HIPAA Code Conversion for Clinical Laboratory Service Providers Coming Soon.

Facts about both Phase 1 and Phase 2 are available on the CHDP Frequently Asked Questions page of the Medi-Cal website.

Providers are encouraged to watch for CHDP updates in the NewsFlash area on the Medi-Cal website, and subscribe to the Medi-Cal Subscription Service (MCSS) to receive timely notifications related to CHDP by completing the MCSS Subscriber Form. Providers with questions or concerns may call the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, except holidays.

Email Address for Questions/Concerns
Providers may submit questions or concerns regarding the CHDP code conversion and claim form transition to CHDPTransition@conduent.com.

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4. 2017 ICD-10-CM Diagnosis Code Annual Update

A previously published NewsFlash article titled “Additional Information: 2017 ICD-10-CM Diagnosis Code Update” notified providers that, with the 2017 annual ICD-10-CM update, a number of diagnosis codes have been expanded for greater detail. The Medi-Cal Provider Manuals and the Family PACT Policies, Procedures and Billing Instructions manual are now updated to reflect these expansions. Deactivated codes have been removed.

Providers should use the new, expanded codes when billing for dates of service on or after October 1, 2016.

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Medical Transportation
Orthotics and Prosthetics
Therapies
cms comp (14)
Chronic Dialysis Clinics inject drug i-m (10); path chem (2–4, 6, 8–10)
Clinics and Hospitals chemo drug p-z (17); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Durable Medical Equipment cms comp (14); incont (8)
Family PACT ben fam rel (8, 10, 13); ben grid (13–15); lab (12–14, 26, 28)
General Medicine chemo drug p-z (17); cms comp (14); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Inpatient Services minor (3)
Long Term Care incont (8)
Obstetrics cms comp (14); ev woman (16, 17); inject drug i-m (10); minor (3); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); radi dia ult (1); radi nuc (1)
Pharmacy cms comp (14); incont (8); inject drug i-m (10)
Psychological Services cms comp (14); spec (2)
Rehabilitation Clinics inject drug i-m (10)
Vision Care minor (3); pro serv cd (2–4, 6, 7)
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5. Updated Drugs and Nutritional Products List Requiring SAR for CCS and GHPP

Effective retroactively for dates of service on or after July 1, 2015, Beneprotein powder is added to the pharmacy list of drugs and nutritional products requiring a separate Service Authorization Request (SAR) for the California Children's Services (CCS) program and the Genetically Handicapped Persons Program (GHPP).

Effective retroactively for dates of service on or after June 1, 2016, Sofosbuvir/Velpatasvir is added to the pharmacy list of drugs and nutritional products requiring a separate SAR for CCS and GHPP.

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
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (8); genetic (9)
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6. New Benefit: SMN1/SMN2 Gene Test

Effective for dates of service on or after June 1, 2017, the SMN1/SMN2 gene test (CPT-4 code 81401, molecular pathology procedure, Level 2) is a Medi-Cal benefit with Treatment Authorization Request (TAR) or Service Authorization Request (SAR) approval.

CPT-4 code 81401 requires providers to document the following on the TAR or SAR, or an attachment to the TAR or SAR:

SMN1/SMN2 (survival of motor neuron 1, telomeric/survival of motor neuron 2, centromeric), dosage analysis. Patient who is considering pregnancy or is already pregnant.

This service is not covered by Medicare and may be billed directly to Medi-Cal.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (20)
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7. SMN1 Gene Tests Clarified for Molecular Pathology

Effective for dates of service on or after June 1, 2017, provider manual text in the entries under SMN1 (survival of motor neuron 1 telomeric) has been clarified regarding gene tests for three CPT-4 codes in molecular pathology. The clarified text is as follows:

CPT-4 Code Description Clarified Language
81400 Molecular pathology procedure, Level 1 Exon 7 deletion
81403 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Known familial sequence variant(s) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal muscular atrophy
81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis Full sequence analysis

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (17, 22, 27)
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8. Respiratory Virus Laboratory Test Code Added to CLIA-Waived List

Effective for dates of service on or after June 1, 2017, CPT-4 code 87633 (infectious agent detection by nucleic acid; respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets) is reimbursable as a Clinical Laboratory Improvement Amendments (CLIA)-waived test when performed with a CLIA-waived test kit and billed with modifier QW (CLIA waived test). This code may also be used without modifier QW if used to bill for services that are not CLIA-waived.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path bil (11)
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9. ICD-10-CM Diagnosis Codes Added For Bevacizumab

Effective retroactively for dates of service on or after October 1, 2015, the following ICD-10-CM diagnosis codes are reimbursable with HCPCS code J9035 (injection, bevacizumab, 10 mg):

E08.311 E10.311 E13.311 H34.832
E08.321 E10.321 E13.321 H34.833
E08.331 E10.331 E13.331 H34.839
E08.341 E10.341 E13.341 H35.32
E08.351 E10.351 E13.351 H35.351
E09.311 E11.311 H34.811 H35.352
E09.321 E11.321 H34.812 H35.353
E09.331 E11.331 H34.813 H35.359
E09.341 E11.341 H34.819 H35.81
E09.351 E11.351 H34.831  

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 (10)
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10. Update to Rates for Select Pathology and Cytopathology CPT-4 Codes

Effective for dates of service on or after December 1, 2016, reimbursement rates have been established for CPT-4 codes 88112 (cytopathology, selective cellular enhancement technique with interpretation, except cervical or vaginal) and 88333 (pathology consultation during surgery; cytologic examination, initial site).

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

For more information, providers may refer to the Medi-Cal Rates web page on the Medi-Cal website.

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11. Two Preventative Medical Evaluations Added as Benefits

Effective for dates of service on or after June 1, 2017, CPT-4 codes 99385 (initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of laboratory/diagnostic procedures, new patient; 18 – 39 years) and 99395 (periodic comprehensive preventative medicine reevaluation and management of an individual … established patient; 18 – 39 years) are added as Medi-Cal benefits.

Codes 99385 and 99395 are Medi-Cal benefits for recipients ages 18 – 21 with no diagnosis or place of service restrictions and a frequency limitation of once per year. The only valid modifiers for this code are as follows:

Modifier National Description
99 Multiple modifiers
SA Nurse practitioner rendering service in collaboration with a physician
SB Nurse midwife
U7 Medicaid level of care 7, as defined by each state

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (15); non ph (8); tar and non cd 9 (8, 21)
Inpatient Services tar and non cd 9 (8)
Rehabilitation Clinics non ph (8, 21)
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12. Update to Reimbursement Rate for Debridement Surgery

Effective for dates of service on or after January 1, 2017, the rate for CPT-4 code 11042 (debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) will be updated on the Medi-Cal Rates Web page on the Medi-Cal website.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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13. Policy Update: ECMO/ECLS Age Groups

Effective retroactively for dates of service on or after January 1, 2015, Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Life Support (ECLS) procedures will cover all ECMO/ECLS codes for all age groups (0 – 5 years of age and 6 – 99 years of age).

The following CPT-4 codes are Medi-Cal benefits for ECMO/ECLS procedures that will cover all age groups (0 – 5 years of age and 6 – 99 years of age):

CPT-4 Code Description
33946 Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947 initiation, veno-arterial
33948 daily management, each day, veno-venous
33949 daily management, each day, veno-arterial
33951 insertion of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33953 insertion of peripheral cannula(e), open, birth through 5 years of age
33955 insertion of peripheral cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33957 reposition of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33959 reposition of peripheral cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33963 reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33965 removal of peripheral cannula(e), percutaneous, birth through 5 years of age
33969 removal of peripheral cannula(e), open, birth through 5 years of age
33985 removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33987 Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS
33988 Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
33989 Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

In order to perform ECMO/ECLS for infants, the institution must be a California Children’s Services (CCS) approved Neonatal Intensive Care Unit (NICU) as both a regional NICU and an ECMO center. The institution must also be capable of providing inhaled nitric oxide services for neonates for children.

In order to perform ECMO for recipients awaiting lung transplantation, the institution must be a Medi-Cal approved Center of Excellence for lung transplantation and have performed ECMOs on adults for a minimum of three years and performed an average of five ECMOs per year.

Daily overall management of the recipient may be separately reported using the relevant hospital inpatient services or critical care evaluation and management codes (99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 and 99480) and may be reimbursed to any provider, same recipient and same date of service.

Services must be submitted on the claim with all revenue/sick baby codes applicable to the entire stay. An infant claim must be submitted for services rendered to the baby only. Care for the mother is billed separately.

The following are revenue codes for ECMO services provided to newborns, infants and children, and adults:

Revenue Code Description
174 Nursery, Newborn; Level IV (newborn 0-28 days)
202 Intensive Care, Medical (adults)
203 Intensive Care, Pediatric (infants and children)

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Rehabilitation Clinics
modif used (11)
Clinics and Hospitals
General Medicine
medne (4–7); modif used (11); tar and non cd3 (5, 6)
Inpatient Services medne (4–7); tar and non cd3 (5, 6)
Obstetrics modif used (11); tar and non cd3 (5, 6)
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14. Updated PE4PW Patient Fact Sheet Available in 12 Languages

The Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet is updated and available in 12 languages:

Providers can access the updated fact sheets on the Presumptive Eligibility for Pregnant Women and Forms pages of the Medi-Cal website.

Providers are encouraged to frequently check the Medi-Cal website for updates.

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15. 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 April 1, 2017
NDC Labeler Code Contracting Company's Name
70199 CASPER PHARMA LLC
70504 APTEVO BIOTHERAPEUTICS LLC
70839 NODEN PHARMA USA, INC.
70860 ATHENEX PHARMACEUTICAL DIVISION, LLC
Terminations, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
60842 KALEO, INC.

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 (13, 18, 19)
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16. Improving the Quality of Care: Overutilization of Proton Pump Inhibitors

A new DUR Educational Article titled “Improving the Quality of Care: Overutilization of Proton Pump Inhibitors” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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17. Alert: Medi-Cal Expands Access to Adult Immunizations in Pharmacies

A new DUR Educational Article titled “Alert: Medi-Cal Expands Access to Adult Immunizations in Pharmacies” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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18. FQHC/RHC/IHS-MOA Local Code Conversion Webinar Monday, July 31, 2017

Providers now have the opportunity to attend free online webinars pertaining to the October 2017 code conversion implementation and billing services for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services/Memorandum of Agreement (IHS/MOA) facilities. The first of these webinars will be presented live through the Medi-Cal website on Monday, July 31, 2017, at 1:00 p.m.

First-time webinar attendees must register online at the Medi-Cal Learning Portal prior to attending. Once registered, select “Course Catalog” from the menu and then select “Calendar View” to locate the appropriate webinar.

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19. June 2017 Medi-Cal Provider Training Webinars

Beginning June 1, 2017, and continuing throughout the month of June, Medi-Cal providers may participate in provider training webinars:

Providers will be able to print class materials and ask questions during the training sessions. Recorded webinars will be archived and available for on-demand viewing from the MLP.

To view the webinars, providers must have Internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach and Education page of the Medi-Cal website.

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20. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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