Medi-Cal Update

Clinics and Hospitals | May 2018 | Bulletin 524

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1. A New Way to Subscribe – Contact Medi-Cal Subscription Service Representatives

Medi-Cal is committed to keeping you up-to-date on the latest Medi-Cal news and policy updates.

The Medi-Cal Subscription Service (MCSS) is a free service that provides subscribers with personalized email notifications for urgent, high-impact announcements and monthly news/policy updates as they post to the Medi-Cal website.

Providers can now contact MCSS representatives directly at MCSSCalifornia@conduent.com to subscribe and for assistance with managing subscriptions. Subscribing is simple and free!

If you have not yet subscribed to MCSS, Medi-Cal encourages you to utilize one of the following two methods to subscribe.

To subscribe by email:

  1. Download the linked MCSS Subscriber Form

  2. Enter your name, email address, ZIP code and subscriber type in the appropriate fields

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Attach your completed form to an email and send to MCSSCalifornia@conduent.com

To subscribe online:

  1. Go to the MCSS Subscriber Form page on the Medi-Cal website

  2. Enter your email address and ZIP code, and select a subscriber type from the drop-down menu

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Click “Subscribe Now” at the bottom of the page

After the form has been received, 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, visit the MCSS Help page.

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2. Valid Revenue Codes for Outpatient Services

For dates of service on or after January 1, 2019, a four-digit revenue code must be included on outpatient claims billed on paper UB-04 claim forms (Box 42) or ANSI 837I transactions for electronic billing (FL42; reference ASC X12N 837 v.5010 Loop 2400 Segment SV201).

A revenue code identifies specific accommodations, ancillary services, or unique billing calculations or arrangements. As defined by the National Uniform Billing Committee (NUBC) and required by the HIPAA, services covered in an outpatient setting require a valid four-digit revenue code to accompany the CPT and HCPCS national procedure code(s).

Outpatient claims with dates of service on or after January 1, 2019, that are submitted on paper UB-04 claim forms or ANSI 837I transactions with missing, incomplete, or invalid revenue codes will be denied.

Providers may contact the Telephone Service Center (TSC) at 1-800-541-5555 for claims assistance.

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3. 2018 Update to PE4PW Income Eligibility Guidelines

Effective January 1, 2018, through December 31, 2018, Presumptive Eligibility for Pregnant Women (PE4PW) providers must use the following income eligibility guidelines to make PE4PW determinations. Providers should disregard all previous PE4PW income eligibility guideline charts.

PE4PW Income Eligibility Guidelines
Effective January 1, 2018, through December 31, 2018
Number of Persons in Family 213 Percent
Monthly Income
213 Percent
Annual Income
2 $2,922 $35,060
3 $3,689 $44,262
4 $4,456 $53,463
5 $5,223 $62,665
6 $5,989 $71,867
7 $6,756 $81,068
8 $7,523 $90,270
9 $8,290 $99,471
10 $9,057 $108,673
11 $9,823 $117,875
12 $10,590 $120,076
For family units of more than 12 members, for each additional member, add: $767 $9,202

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (4)
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4. Reimbursement Rates Established for Select Mammography CPT-4 Codes

Effective for dates of service on or after January 1, 2018, reimbursement rates are established for CPT-4 codes 77065 (diagnostic mammography, including computer-aided detection when performed; unilateral), 77066 (…bilateral) and 77067 (screening mammography, bilateral, including computer-aided detection when performed).

No action is required of providers. Affected claims will be reprocessed with an Erroneous Payment Correction (EPC). For more information, providers may refer to the Medi-Cal Rates page on the Medi-Cal website.

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5. Expanded TAR Clinical Criteria for DNA Sequence Analysis Procedures

Effective for dates of service on or after June 1, 2018, the Treatment Authorization Request (TAR) clinical criteria is expanded for CPT-4 code 81406 (molecular pathology procedure, Level 7 [eg, analysis of 11 – 25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26 – 50 exons, cytogenomic array analysis for neoplasia]). CPT-4 code 81406 may be billed with a TAR documenting any of the following:

  1. The patient is undergoing consideration for treatment using valproic acid, or

  2. The patient is undergoing evaluation for potentially having any one of the following conditions:
    • Alpers-Huttenlocher syndrome

    • Ataxia neuropathy spectrum (ANS), previously known as mitochondrial recessive ataxia syndrome (MIRAS) and sensory ataxia neuropathy, dysarthria and ophthalmoplegia (SANDO)

    • Autosomal dominant progressive external ophthalmoplegia

    • Autosomal recessive progressive external ophthalmoplegia

    • Childhood myocerebrohepatopathy spectrum

    • Myoclonic epilepsy myopathy sensory ataxia

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (51, 52)
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6. Updated TAR Criteria for Familial Hyperinsulinism Gene Analysis

Effective for dates of service on or after June 1, 2018, the Treatment Authorization Request (TAR) criteria related to KCNJ11 (familial hyperinsulinism) gene analysis, which is reimbursable with CPT-4 code 81403 (molecular pathology procedure, Level 4), has expanded.

A TAR may be approved based on one of the following criteria:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (36)
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7. Automated Hemogram and RSV Laboratory Tests Added as CLIA-Waived Services

Effective for dates of service on or after June 1, 2018, the following services are reimbursable as Clinical Laboratory Improvement Amendments (CLIA)-waived tests when performed with a CLIA-waived test kit and billed with modifier QW (CLIA waived test). These codes also may be billed without modifier QW for non-CLIA-waived tests.

CPT-4 Code Description
85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
87634 Infectious agent detection by nucleic acid (DNA or RNA); respiratory syncytial virus, amplified probe technique

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 (12, 13)
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8. 2017 Rate Adjustment for Clinical Laboratory Services

In compliance with Welfare and Institutions Code (W&I Code), Section 14105.22, Medi-Cal maximum reimbursement rates for clinical laboratory or laboratory services may not exceed 80 percent of the lowest maximum allowance established by the federal Medicare program for the same or similar services.

Effective retroactively for dates of service on or after January 1, 2017, reimbursement rates for clinical laboratory services that exceeded 80 percent of the 2017 Medicare rate will be adjusted. An Erroneous Payment Correction will be initiated to adjust claims previously processed under the higher rate.

Providers may refer to the Medi-Cal Rates page of the Medi-Cal website for current posted reimbursement rates.

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9. PL and PS Removed as Allowable Modifiers for Select Pathology Codes

Effective retroactively for dates of service on or after October 1, 2015, modifiers PL and PS are removed as allowable modifiers for the following CPT-4 codes.

CPT-4 Code Description
88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure
88344 each multiplex antibody stain procedure
88365 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure
88364 each additional single probe stain procedure
88366 each multiplex probe stain procedure
88369 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each additional single probe stain procedure
88377 each multiplex probe stain procedure
88373 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure
88374 each multiplex probe stain procedure

Note:

Effective for dates of service on or after April 1, 2018, code 88365 was added as a new Medi-Cal benefit.

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

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path surg (2)
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10. Corrections to 2018 CPT-4/HCPCS Annual Update

A previously published Medi-Cal Update added, changed and deleted CPT-4 and HCPCS codes for the 2018 annual update, effective February 1, 2018. Updates to this policy are as follows:

CPT-4 code 90750 (zoster [shingles] vaccine [HZV], recombinant, subunit, adjuvanted, for intramuscular use) is reimbursable for recipients 50 years of age and older.

The correct policy is reflected in the following PDF document:

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
immun (19)
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11. 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 Provider Orientation training is delivered online and in person and includes information on comprehensive family planning, program benefits and services, client eligibility, provider responsibilities and compliance.

Each provider's service location is required to be certified for enrollment in the Family PACT Program. Applicants who are enrolled in Medi-Cal and in good standing or are pending Medi-Cal enrollment and who have submitted a Family PACT application packet may complete the Provider Orientation to certify a site for enrollment.

Each service location must designate one eligible representative to be the site certifier. The site certifier cannot certify multiple sites.

The medical director, physician, nurse practitioner or certified nurse midwife who is responsible for overseeing the family planning services rendered at the location to be enrolled is eligible to certify the site.

Provider Orientation details and registration information is posted on the Family PACT website at www.familypact.org.

Upcoming In-Person Orientation

Los Angeles
June 28, 2018
8:30 a.m. – 12:30 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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12. June 2018 Medi-Cal Provider Training Webinars

Beginning June 5, 2018, 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 & Education page of the Medi-Cal website.

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

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The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post 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 and select a subscriber type

  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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14. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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Note:

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