Medi-Cal Update

Clinics and Hospitals | December 2017 | Bulletin 519

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1. 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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2. Every Woman Counts Mammography Billing Codes Update

Effective for dates of service on or after October 1, 2017, the following mammography codes are new benefits for the Every Woman Counts (EWC) program:

CPT-4 Code Description
77065 Diagnostic mammography, including computer-aided detection (CAD); unilateral
77066 Diagnostic mammography, including computer-aided detection (CAD); bilateral
77067 Screening mammography, bilateral

Billers may refer to the Medi-Cal Part 2 manual section, Every Woman Counts Billing Examples: UB-04, for a screening mammography claim example.

EWC policy for code 77067 is as follows:

EWC policy for codes 77065 and 77066 is as follows:

The Medi-Cal claims processing system is being updated to process claims with CPT-4 codes 77065 – 77067. Once the system is ready, denied claims submitted for dates of service on or after October 1, 2017, will be subject to an Erroneous Payment Correction (EPC).

No Longer Reimbursable
Effective for dates of service on or after October 1, 2017, the following codes are no longer benefits for the Every Woman Counts program.

CPT-4 Code Description
77055 Mammography; unilateral
77056 Mammography; bilateral
77057 Screening mammogram; bilateral

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

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
ev woman (8, 23, 24, 32, 33)
Clinics and Hospitals ev woman (8, 23, 24, 32, 33); ev woman ex ub (2, 3)
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3. Cerliponase Alfa Added for CCS and GHPP

Effective retroactively for dates of service on or after May 1, 2017, cerliponase alfa is added to the pharmacy list of drugs and nutritional products for the California Children's Services (CCS) program and the Genetically Handicapped Persons Program (GHPP).

Cerliponase alfa is not included in a physician Service Code Grouping (SCG) and requires a separate Service Authorization Request (SAR).

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-Bases Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (7); genetic (10)
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4. Correction: Cystourethroscopy Services Non-Benefits for Assistant Surgeons

An article published in the June 2017 Medi-Cal Update mistakenly identified CPT-4 code 52441 (cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant) and code 52442 (…each additional permanent adjustable transprostatic implant) as benefits for assistant surgeons. These codes are not benefits for assistant surgeons.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
surg urin (6); tar and non cd5 (3)
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5. Correction: NDC Labeler Code for UCB PHARMA, INC.

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section incorrectly listed UCB PHARMA, INC. with NDC labeler code 50458. The correct NDC labeler code is 50474.

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section is updated to reflect the correct NDC labeler code.

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)
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6. ICD-10-CM Diagnosis Codes Added for Bevacizumab

Effective retroactively for dates of service on or after October 1, 2016, the following ICD-10-CM diagnosis codes are reimbursable with HCPCS code J9035 (injection, bevacizumab, 10 mg):

E08.3211 – E08.3213 E11.3311 – E11.3313
E08.3219 E11.3319
E08.3311 – E08.3313 E11.3411 – E11.3413
E08.3319 E11.3419
E08.3411 – E08.3413 E11.3511 – E11.3513
E08.3419 E11.3519
E08.3511 – E08.3513 E13.3211 – E13.3213
E08.3519 E13.3219
E09.3211 – E09.3213 E13.3311 – E13.3313
E09.3219 E13.3319
E09.3311 – E09.3313 E13.3411 – E13.3413
E09.3319 E13.3419
E09.3411 – E09.3413 E13.3511 – E13.3513
E09.3419 E13.3519
E09.3511 – E09.3513 H34.8110 – H34.8112
E09.3519 H34.8120 – H34.8122
E10.3211 – E10.3213 H34.8130 – H34.8132
E10.3219 H34.8190 – H34.8192
E10.3311 – E10.3313 H34.8310 – H34.8312
E10.3319 H34.8320 – H34.8322
E10.3411 – E10.3413 H34.8330 – H34.8332
E10.3419 H34.8390 – H34.8392
E10.3511 – E10.3513 H35.3210 – H35.3213
E10.3519 H35.3220 – H35.3223
E11.3211 – E11.3213 H35.3230 – H35.3233
E11.3219 H35.3290 – H35.3293

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
Clinics and Hospitals
General Medicine
chemo drug a-d (11, 12); ophthal (6, 7)
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7. Cuvitru Added as Medi-Cal Benefit for Primary Humoral Immunodeficiency

Effective retroactively for dates of service on or after January 1, 2017, Cuvitru is a new Medi-Cal benefit as replacement therapy for primary humoral immunodeficiency in adult and pediatric patients 2 years of age and older, for subcutaneous infusion only. Cuvitru is billable under HCPCS code J3590 (unclassified biologics) in conjunction with a Treatment Authorization Request (TAR).

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
Pharmacy
Rehabilitation Clinics
inject an over (3); inject cd list (4); inject drug a-d (29, 30)
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8. New Modifier ZA Required for HCPCS Code Q5101

Effective retroactively for dates of service on or after January 1, 2016, modifier ZA (Novartis/Sandoz) is required when billing for Zarxio with HCPCS code Q5101 (injection, filgrastim [g-csf], biosimilar, 1 microgram). Modifier ZA was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZA (anesthesia procedures complicated by unusual position or surgical field avoidance) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

An Erroneous Payment Correction (EPC) will be generated to accurately adjudicate claims submitted with the CMS modifier ZA with dates of service on or after January 1, 2016.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject drug e-h (20); modif app (21, 25)
Pharmacy inject drug e-h (20)
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9. VeriFone VX 520 POS Device to Decommission in July 2018

In July 2018, the VeriFone VX 520 Point of Service (POS) device will be decommissioned. Providers may contact the POS Help Desk at 1-800-541-5555 (option 5, followed by option 6) for information about the decommission and for options.

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10. FQHC/RHC/IHS-MOA Code Conversion Reminder

Effective for dates of service on or after October 1, 2017, the FQHC/RHC/IHS-MOA code conversion established HIPAA-compliant billing code sets for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services-Memorandum of Agreement (IHS-MOA) 638, clinics.

The Health Insurance Portability and Accountability Act (HIPAA) was authorized by Congress in 1996. HIPAA mandates uniform, national standards for information submitted by health care providers on claims, including health care services, procedures and personal health information.

These HIPAA-compliant billing code sets replaced local codes previously used by FQHCs, RHCs and IHS-MOA clinics for medical and/or mental health services. Code crosswalks for this conversion are available on the HIPAA: Code Conversions Web page of the Medi-Cal website under the FQHC/RHC/IHS-MOA heading:

Note: Code sets listed in these crosswalks are billable as of October 1, 2017.

Additional information regarding this code conversion published throughout 2017 in the NewsFlash, Medi-Cal Updateand on the HIPAA: Code Conversions web page.

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11. 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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12. 2018 Medi-Cal Provider Training Schedule

The 2018 Medi-Cal provider training schedule is now available. Providers can access Medi-Cal training information and registration details by clicking on the Outreach & Education slideshow area of the Medi-Cal website homepage or by visiting the Training Calendar web page of the Medi-Cal Learning Portal (MLP).

Training Date Webinar or Seminar Location Address
January 2 – 31 Webinar Information posted on the Medi-Cal website
February 13 – 14 Seminar Ontario
Ontario Airport Hotel & Conference Center
700 North Haven Ave.
Ontario, CA  91764
March 13 Seminar Redding
Red Lion Hotel Redding
1830 Hilltop Drive
Redding, CA  96002
April 18 – 19 Seminar Escondido
California Center For The Arts
340 N. Escondido Blvd.
Escondido, CA  92025
May 15 – 16 Seminar Fresno
Double Tree Hilton
2233 Ventura Street
Fresno, CA  93721
June 5 – 28 Webinar Information to be posted on the Medi-Cal website
July 17 – 18 Seminar Alhambra
Almansor Court
700 S. Almansor Court St.
Alhambra, CA  91801
August 14 – 15 Seminar Sacramento
Sacramento Marriott
11211 Point East Drive
Rancho Cordova, CA  95742
September 18 – 19 Seminar Long Beach
Long Beach Marriott
4700 Airport Plaza Drive
Long Beach, CA  90815
October 16 – 17 Seminar Concord
Crown Plaza
45 John Glen Drive
Concord, CA  94520
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13. January 2018 Medi-Cal Provider Training Webinars

Beginning January 2, 2018, and continuing throughout the month of January, 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 & Education web page of the Medi-Cal website.

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14. 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
February 15, 2018
10:00 a.m. – 2:00 p.m.
California Endowment
2000 Franklin Street
Oakland, CA  94612
Sacramento
March 13, 2018
9:00 a.m. – 1:00 p.m.
Sierra Health
1321 Garden Highway
Sacramento, CA  95833

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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15. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

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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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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