Medi-Cal Update

Clinics and Hospitals | October 2017 | Bulletin 517

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1. Revisions to 2017 CPT-4/HCPCS Annual Update

A previously published Medi-Cal Update added, changed and deleted CPT-4 and HCPCS codes for the 2017 annual update, effective October 1, 2017. The following policy has been revised:

Medicine
CPT-4 code 92242 (fluorescein angiography and indocyanine-green angiography [includes multiframe imaging] performed at the same patient encounter with interpretation and report, unilateral or bilateral) is split-billable and modifiers TC and 26 are required. Modifier 22 is allowable. Modifiers SA, SB and U7 are not allowable.

The Place of Service restrictions for CPT-4 code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) are removed.

CPT-4 codes 99151 (moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age), 99152 (…initial 15 minutes of intraservice time, patient age 5 years or older) and 99153 (…each additional 15 minutes of intraservice time) are exempt from the modifier 51 reimbursement cutback.

Modifiers SA and SB are allowable for CPT-4 code 99156 (moderate sedation services provided by a physician or other qualified health care professional other than the physician or qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older) and HCPCS code G0500 (moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older).

CPT-4 code 99157 (moderate sedation services provided by a physician or other qualified health care professional other than the physician or qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time) is exempt from the modifier 51 reimbursement cutback and modifiers SA and SB are allowable.

Radiology
CPT-4 code 77789 (surface application of low dose rate radionuclide source) is split-billable and modifiers TC and 26 are allowable.

HCPCS codes A9587 (gallium ga-68, dotatate, diagnostic, 0.1 millicurie) and A9588 (fluciclovine f-18, diagnostic, 1 millicurie) include “millicuries” in their descriptors and reimbursement is allowed as per their descriptors. A Treatment Authorization Request (TAR) override is allowed.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics modif used (6, 11)
Clinics and Hospitals General Medicine modif used (6, 11); non ph (8, 21, 22); ophthal (2, 3); radi nuc (6, 7); radi onc (2–4); respir (4); surg bil mod (8); tar and non cd3 (7)
Durable Medical Equipment
Therapies
respir (4)
Inpatient Services tar and non cd3 (7)
Obstetrics modif used (6, 11); non ph (8, 21, 22); radi nuc (6, 7); radi onc (2–4); surg bil mod (8); tar and non cd3 (7)
Rehabilitation Clinics modif used (6, 11); non ph (8, 21, 22); respir (4)
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2. 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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4. HIV Screening and Infectious Agent Detection Codes Added to CLIA-Waived List

Effective for dates of service on or after November 1, 2017, HCPCS code G0475 (HIV antigen/antibody, combination assay, screening) and CPT-4 code 87801 (infectious agent detection by nucleic acid [DNA or RNA], multiple organisms; amplified probe(s) technique) are 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). These codes 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 (9, 13)
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5. New Benefit for Pathogen(s) Test for Platelets

Effective for dates of service on or after July 1, 2017, HCPCS code Q9987 (pathogen(s) test for platelets) is a Medi-Cal benefit. The frequency limitation is once per month.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
blood (7); path micro (5)
Chronic Dialysis Clinics
Pharmacy
blood (7)
Obstetrics path micro (5)
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6. New Immunization and Vaccines FAQs

New Frequently Asked Questions (FAQs) titled “Medi-Cal Coverage of Immunizations” and “Pharmacy-Administered Vaccines in California” have been published to the FAQs page of the Medi-Cal website.

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7. Identifying Surgical Follow-Up Time Periods

Updated instructions for identifying surgical follow-up (global) time periods are added to the Evaluation and Management (E&M) manual section of the Part 2 Medi-Cal provider manual.

Surgical follow-up periods (referred to as global days) are listed in the relative value (RVU) files of the latest quarterly physician fee schedule on the Centers for Medicare & Medicaid Services website. Providers should not refer to the 1969 California Relative Value Studies (CRVS) for surgical follow-up time periods.

Tips:

To locate files containing surgical procedure codes and associated follow-up (global) time periods, providers should enter “PPRVU” in the search box on the CMS website home page. PPRVU spreadsheets are released quarterly. Quarter one files end in the letter A, quarter two files end in the letter B and so on. Within the PPRVU spreadsheet, providers should refer to the “Glob Days” column for follow-up (global) time frames.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (12)
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8. Update to Reimbursement Rates for Skin Lesion Surgery Codes

Effective retroactively for dates of service on or after January 1, 2017, the maximum reimbursement rates for CPT-4 codes 17110 (destruction, of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) and 17111 (…15 or more lesions) are updated.

No action is required of providers. Affected claims will be reprocessed via an Erroneous Payment Correction.

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

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9. Non-Every Woman Counts Claims Erroneously Denied with RAD Code 0033

The Department of Health Care Services (DHCS) identified a claims processing issue causing claims billed with HCPCS infusion codes (J7030, J7040, J7050, and J7120) to erroneously deny with Remittance Advice Details (RAD) Code 0033: The recipient is not eligible for the special program billed and/or restricted services billed.

DHCS and the Medi-Cal Fiscal Intermediary are working to resolve this issue. Affected claims may be reprocessed via a future Erroneous Payment Correction; therefore, providers should continue to bill their claims timely and check for updates on the Medi-Cal website.

For Physician-Administered Drugs billing instructions, please refer to the appropriate Part 2 Provider Manual sections.

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10. Boulder City Added as Border City for Specific Field Offices and Services

Effective immediately, Boulder City, Nevada is added as a Border City for the following Medi-Cal Field Offices and their respective services:

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
tar field (4, 8, 9, 11)
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11. Billing Tips: Outpatient Services

When billing for injections and infusions, providers must use the appropriate HCPCS codes with matching packet sizes (including the invoice, if applicable). Otherwise, claims may be denied with Remittance Advice Details (RAD) code 9898: HCPCS Qualifier and NDC (National Drug Code)/UPN (Universal Product Number) is invalid. Please follow the billing guidelines located in the appropriate part 2 provider manual.

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12. Alert: Online Report to the Vaccine Adverse Event Reporting System (VAERS)

A new DUR Educational Article titled “Alert: Online Report to the Vaccine Adverse Event Reporting System (VAERS)” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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13. 2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines

A new DUR Educational Article titled “2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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14. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically
  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 278 transactions
    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 278 transactions

Registered providers, clearinghouses or Managed Care Plans can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

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 (1, 12); genetic (4, 5)
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15. National Correct Coding Initiative Quarterly Update for October 2017

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative 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 October 1, 2017.

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

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16. Provider Orientation

Family PACT

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Family PACT Provider Orientation provides an overview of the Family PACT Program, provider enrollment process, program standards and benefits and client eligibility and enrollment.

Solo or group providers or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility.

The Family PACT Provider Orientation is delivered in two parts. Part one consists of an online orientation that must be completed prior to attending a part two in-person orientation. Medi-Cal providers who wish to enroll in the Family PACT Program will be required to complete both the online orientation and attend the in-person orientation. The Family PACT Provider Orientation is open to all site staff.

Complete the orientation process by following three simple steps:

  1. Visit: http://www.ofpregistration.org/ to register and create a profile in the Office of Family Planning Learning Management System (LMS). Once your profile has been set up, you are ready to proceed with the orientation.
  2. Complete part one of the orientation. Part one must be completed in order to register for the (part two) in-person orientation. Print the Certification of Completion when you have completed the online orientation.
  3. Complete part two by attending the in-person orientation. Register through the LMS and select an in-person orientation session. Site certifiers must attend the in-person orientation and are required to present photo identification during registration.

Upcoming In-Person Orientation

Oakland
October 25, 2017
10:00 a.m. – 2:00 p.m.
California Endowment
2000 Franklin Street
Oakland, CA  94612
Los Angeles
December 5, 2017
1:00 p.m. – 5:00 p.m.
California Endowment
1000 North Alameda Street
Los Angeles, CA  90012

Please contact the Office of Family Planning by phone (916) 650-0414 or email us at ProviderServices@dhcs.ca.gov if you have any questions regarding the orientation process.

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17. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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