Medi-Cal Update

Clinics and Hospitals | January 2019 | Bulletin 532

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1. 2019 HCPCS Annual Update: Policy Updates

The 2019 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2019 HCPCS Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for dates of service on or after February 1, 2019. Providers should refer to the 2019 HCPCS Level II code book for complete descriptions of these codes.

Providers should refer to the HCPCS Annual Update page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Therapies
Vision Care
medi non hcp (2)
Audiology and Hearing Aids hear aid bill (3, 4); hear aid cd (1, 3); medi non hcp (2); tax (10)
Chronic Dialysis Clinics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12)
Clinics and Hospitals
General Medicine
chemo an over (2); chemo drug a-d (3, 8, 23, 24, 31); chemo drug e-o (7, 8, 18, 21); chemo drug p-z (9–12, 19, 20); inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); medne tele (5); modif used (12); non ph (12–14, 25–27); once (1); ophthal (16); radi dia ult (3); radi onc (7–9); surg eye (14); surg integ (5); surg nerv (3)
Durable Medical Equipment
Orthotics and Prosthetics
medi non hcp (2); tax (10)
Obstetrics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12); non ph (12–14, 25–27); once (1); radi dia ult (3); radi onc (7–9)
Pharmacy inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); tax (10)
Rehabilitation Clinics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12); non ph (12–14, 25–27)
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2. Correction to 2019 CPT Annual Update

A previously published Medi-Cal Update that added, changed and deleted CPT codes for the 2019 annual update, effective January 1, 2019, did not contain the following policy for CPT codes 76391, 76978, 76979, 76981, 76982 and 77046 – 77049:

CPT codes 76978, 76979, 76981 and 76982 are split-billable and should be billed with modifier TC when billing only for the technical component, and modifier 26 when billing only for the professional component. Modifier 99 must not be billed in conjunction with modifier 26 or modifier TC. The claim will be denied.

CPT codes 76391 and 77046 – 77049 must be billed with modifiers TC or 26.

This policy is reflected in the 2019 CPT Policy Updates PDF.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (10); radi dia ult (4)
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3. Diabetes Prevention Program: New Medi-Cal Benefit Coming in 2019

Effective for dates of service on or after January 1, 2019, the Diabetes Prevention Program (DPP) will be a Medi-Cal covered benefit.

Medi-Cal’s program will be consistent with the federal Centers for Disease Control and Prevention’s (CDC’s) guidelines and will also incorporate many components of the Centers for Medicare & Medicaid Services’ (CMS’) DPP in Medicare.

Medi-Cal providers choosing to offer DPP services must comply with CDC guidance and obtain CDC recognition in connection with the National Diabetes Prevention Recognition Program. Medi-Cal’s DPP will include a core benefit consisting of at least 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. In addition, participants who achieve and maintain a required minimum weight loss of 5 percent from the first core session will also be eligible to receive ongoing maintenance sessions, after the 12-month core services period, to help them continue healthy lifestyle behaviors. The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

DPP Claim Submission Delay
DPP coverage and reimbursement policy is available on the Department of Health Care Services (DHCS) Diabetes Prevention Program web page. Once the necessary California Medicaid Management Information System (CA-MMIS) system edits are complete, this information will be published in the appropriate Part 2 Medi-Cal Update bulletins and provider manuals (see following manual and bulletin information). Then, when instructed, Medi-Cal fee-for-service providers may begin submitting and billing for DPP services. In the interim, Medi-Cal fee-for-service providers are instructed to hold all DPP claims until further notice from the Department.

Medi-Cal Provider Manuals and Bulletins
Health professionals interested in providing DPP services may be new to Medi-Cal’s series of provider manuals and bulletins, which are tailored by types of services rendered. A bulletin is a monthly newsletter. The provider manual is a series of chapters (sections) constantly updated to keep providers educated about policy and billing. Providers may choose any one of the following monthly bulletins to check for DPP articles and policy updates; and later in 2019, the associated provider manual updates:

Additional Information
To ensure providers stay up-to-date with important DPP information, the Department encourages providers to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to the upcoming changes. Providers may sign up for MCSS by completing the MCSS Subscriber Form.

Questions and comments may be emailed to DHCSDPP@dhcs.ca.gov.

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4. Correction: EPSDT Psychology, Mental and Behavioral Health Code Conversion

In October and December 2018, policy information and resources were published regarding the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health code conversion. The policy effective date for this conversion has changed and will be provided at a later date.

All materials published regarding the EPSDT psychology, mental and behavioral health code conversion will be updated to reflect this change.

Providers are encouraged to visit the EPSDT Services: Psychology, Mental and Behavioral Health section of the HIPAA: Code Conversions web page for updates and additional resources.

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5. EPSDT PDHC and PDN: TAR Submission Update

Effective immediately, providers rendering Pediatric Day Health Care (PDHC) or Private Duty Nursing (PDN) services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit must indicate so on their Treatment Authorization Requests (TARs).

For electronic TARs (eTARs), providers must select the appropriate special handling code on the Patient Information page:

For paper 50-1 TARs, providers must include “EPSDT PDHC” or “EPSDT PDN” in the Specific Services Requested field (Box 10A).

For additional TAR information, contact: PDNinquiries@dhcs.ca.gov.

Any email containing protected health information (PHI) or personal information (PI) should be sent via secure or encrypted email.

Note:

California Children’s Services’ (CCS) Service Authorization Requests (SARs) are not affected by this update.

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
Inpatient Services
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Therapies
Pharmacy
tar comp (8); tar field (2); cal child (3)
Adult Day Health Care Centers
Heroin Detoxification
Hospice Care Program
tar comp (8); tar field (2)
Long Term Care tar field (2)
Home Health Agencies/Home and Community-Based Services ped (3); tar comp (8); tar field (2); cal child (3)
Local Educational Agency
Vision Care
cal child (3)
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6. Cladribine is a New Medi-Cal Benefit

Effective retroactively for dates of service on or after December 1, 2008, HCPCS code J9065 (injection, cladribine, per 1 mg) is a Medi-Cal benefit.

Cladribine is indicated for the treatment of recipients of all ages with neoplastic conditions such as hairy cell leukemia.

The recommended dosage varies depending on the recipient's age, treatment condition, and response to therapy and may range from 0.09 – 1.4 mg/kg/day given as an intravenous infusion from between one to seven days per cycle. If the dosage exceeds the billing limitation of 25 mg per day, a Treatment Authorization Request (TAR) is required for reimbursement.

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
Chronic Dialysis Clinics
Pharmacy
inject cd list (4)
Clinics and Hospitals
General Medicine
chemo drug a-d (22); inject cd list (4); non ph (26)
Obstetrics
Rehabilitation Clinics
inject cd list (4); non ph (26)
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7. Frequency Limit/TAR Restriction Updates for EWC Mammography CPT Codes

Effective retroactively for dates of service on or after October 1, 2017, frequency limitations and Treatment Authorization Request (TAR) requirements no longer apply to Every Woman Counts (EWC) program mammography services billed with CPT codes 77065 (diagnostic mammography, including computer-aided detection [CAD] when performed; unilateral) and 77066 (diagnostic mammography, including computer-aided detection [CAD] when performed; bilateral).

Effective retroactively for dates of service on or after October 1, 2017, EWC program mammography services billed with CPT code 77067 (screening mammography, bilateral [2-view study of each breast], including computer-aided detection [CAD] when performed) are limited to one screening per 365 days, any provider.

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
ev woman (25, 26)
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8. Every Woman Counts Program Addition of New Data Entry Fields for DETEC

Effective for dates of service on or after January 2, 2019, the Every Woman Counts (EWC) Program has implemented two new data fields in the EWC data entry applications known as DETEC (DETecting Early Cancer) for High Risk for Breast Cancer and High Risk for Cervical Cancer. The collection of this data is required by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) of the Center for Disease Control and Prevention (CDC).

This update is reflected in the Every Woman Counts Step-by-Step User Guide.

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9. Reimbursable USPSTF and ACIP Preventive Services Specified

In accordance with the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices, reimbursable Medi-Cal preventive services are specified with applicable billing codes.

U.S. Preventive Services Task Force (USPSTF)
USPSTF grade A and B recommended preventive services are covered through Medi-Cal without cost-sharing. The full recommendations are on the USPSTF A and B Recommendations web page of the USPSTF website. It is important to read the actual USPSTF recommendations to determine the population-specific criteria for each recommendation.

Advisory Committee on Immunization Practices (ACIP)
Certain vaccines are reimbursable for use in adults 19 years of age or older, as recommended by the ACIP and approved by the Centers for Disease Control and Prevention (CDC). There is no cost-sharing for Medi-Cal recipients who receive these vaccinations.

The recommended immunization schedules for adults by age group or by medical condition or other indications are available on the CDC ACIP website.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
prev (1–12)
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10. National Correct Coding Initiative Quarterly Update for January 2019

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) 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 January 1, 2019.

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

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11. 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 January 1, 2019
NDC Labeler Code Contracting Company's Name
00254 PAR PHARMACEUTICAL INC.
10148 COTHERIX, INC.
16781 ONSET DERMATOLOGICS LLC
24689 APNAR PHARMA LP
42192 ACELLA PHARMACEUTICALS, LLC
46017 MYLAN CONSUMER HEALTHCARE, INC.
50228 SCIEGEN PHARMACEUTICALS, INC.
52856 PTC THERAPEUTICS, INC.
61145 REPHARM LLC
69292 AMICI PHARMACEUTICALS LLC
69557 SCILEX PHARMACEUTICALS
70127 GREENWICH BIOSCIENCES INC.
70428 DERMIRA, INC.
70594 XELLIA PHARMACEUTICALS USA, LLC
70677 MCKESSON CORPORATION
70726 ITF PHARMA, INC.
71258 PROGENICS PHARMACEUTICALS, INC.
71336 ALNYLAM PHARMACEUTICALS, INC.
71369 AKARX, INC.
71558 INSMED INCORPORATED
71717 MEGALITH PHARMACEUTICALS INC.
71773 TETRAPHASE PHARMACEUTICALS, INC.
71779 VERASTEM, INC.
71904 AMICUS THERAPEUTICS, INC.
72126 AKCEA THERAPEUTICS, INC.
72205 NOVADOZ PHARMACEUTICALS, LLC
72245 FORTE BIO-PHARMA LLC
72511 AMGEN USA 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 (4, 5, 7–11, 13, 18–20)
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12. 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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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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