Medi-Cal Update

Clinics and Hospitals | October 2019 | Bulletin 541

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1. Certain Induce Abortion Procedure Codes Exempt from Payment Reduction

Effective retroactively for dates of service on or after July 1, 2017, CPT codes 59840 (induced abortion, by dilation and curettage) and 59841 (induced abortion, by dilation and evacuation) are exempt from the 10 percent provider payment reduction authorized by Assembly Bill 97 (Chapter 3, Statutes of 2011).

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

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2. Drug Onasemnogene Abeparvovec-xioi Requires Own SAR

Effective for dates of service on or after May 1, 2019, the drug onasemnogene abeparvovec-xioi is excluded from any California Children’s Services and Genetically Handicapped Persons Program (GHPP) Service Code Grouping (SCG). Therefore, providers must submit a separate Service Authorization Request (SAR) for the drug.

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 (7, 8); genetic (11)
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3. Clarification: EWC Covered Procedures Quick Reference Sheets Update

A previously published article titled “EWC Covered Procedures Quick Reference Sheets Update” notified providers of updates to the Every Woman Counts (EWC) quick reference sheets. In addition to those updates, CPT code 87625 (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed) was added to the following EWC quick reference sheets:

CPT code 10022 (fine needle aspiration; with imaging guidance) was also removed from the two sheets listed above as well as from the Breast Only Primary Care Provider Covered Procedures (DHCS 8471) quick reference sheet.

These forms can be found on the Every Woman Counts (EWC) Manuals, Forms and Worksheets page of the Medi-Cal website.

Additionally, the following CPT codes were erroneously excluded from Figure 3 in the Every Woman Counts section of the appropriate Part 2 manual: CPT codes 19286 (placement of breast localization device(s), percutaneous; each additional lesion, including ultrasound guidance), 87625 (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed) and 88164 (cytopathology, slides, cervical or vaginal [the Bethesda System]; manual screening under physician supervision). These codes may be billed to EWC by referral 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 (40)
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4. Hospice Recipients are Eligible for End of Life Option Act Services

Medi-Cal would like to clarify that beneficiaries who have elected to receive hospice care are also eligible for End of Life Options Act services, including aid-in-dying drugs and medical services related to prescribing these drugs.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eloa (2); hospic (11)
Hospice Care Programs
Inpatient Services
hospic (11)
Pharmacy
Psychological Services
eloa (2)
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5. Scleral Contact Lens Is a Medi-Cal Benefit

Effective for dates of service on or after November 1, 2019, HCPCS code V2531 (contact lens, scleral, gas permeable, per lens) is a Medi-Cal benefit. The maximum number of units allowed is two per claim, any provider. Modifier NU or RA is required. HCPCS code V2531 is billed “By Report,” and an approved Treatment Authorization Request (TAR) is required for reimbursement.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
ophthal (1)
Vision Care contact lens (4, 5); modif used vc (4); pia (4); pro serv (1); rates max eye app (6); tar comp vc (2)
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6. Rate Update for Certain Skin Substitute Products

Effective for dates of service on or after July 1, 2019, the rates for the following HCPCS codes are updated:

HCPCS Code Description
Q4101 Apligraf, per square centimeter
Q4102 OASIS Wound Matrix, per square centimeter
Q4106 Dermagraft, per square centimeter
Q4107 GRAFTJACKET, per square centimeter
Q4110 PriMatrix, per square centimeter
Q4111 GammaGraft, per square centimeter
Q4121 TheraSkin, per square centimeter
Q4132 Grafix CORE and GrafixPL CORE, per square centimeter
Q4133 Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per square centimeter
Q4159 Affinity, per square centimeter
Q4160 NuShield, per square centimeter
Q4170 Cygnus, per square centimeter
Q4186 EpiFix, per square centimeter
Q4195 PuraPly, per square centimeter
Q4196 PuraPly AM, per square centimeter

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

For a list of current rates, providers may visit the Medi-Cal Rates page of the Medi-Cal website.

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7. ICD-10-CM Diagnosis Codes Added for BRAF Gene Analysis

Effective for dates of service on or after November 1, 2019, ICD-10-CM diagnosis codes C33, C34.00 – C34.92 are reimbursable when submitted with once-in-a-lifetime CPT code 81210: BRAF (B-Raf proto-oncogene, serine/threonine kinase), gene analysis, V600 variant(s).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (12)
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8. TAR Requirements Updated for Gene Analysis Benefit

Effective for dates of service on or after November 1, 2019, the Treatment Authorization Request (TAR) criteria and billing requirements for CPT code 81162 (BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis) have been updated to include 2019 U.S. Preventive Services Task Force (USPSTF) recommendations.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (3)
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9. Evocative and Suppression Panel Tests Now Medi-Cal Benefits

Effective for dates of service on or after November 1, 2019, CPT codes 80400-80439 (evocative/suppression panel tests) have been added as a Medi-Cal benefits.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
non ph (9); path bil (19); tar and non cd8 (1)
Inpatient Services tar and non cd8 (1)
Rehabilitation Clinics non ph (9)
Chronic Dialysis Clinics path bil (19)
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10. Office Consultations May Be Conducted at Urgent Care Facilities

Effective retroactively for dates of service on or after January 1, 2003, Place of Service code “20” (Urgent Care Facility) is added to Evaluation and Management (E&M) consultation codes 99241 – 99245 (office evaluation).

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

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (7)
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11. FQHC/RHC Annual Rate Adjustment

Effective for dates of service on or after October 1, 2019, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) received an annual rate adjustment. Under the Prospective Payment System (PPS), reimbursement rates are increased by 1.5 percent to reflect the current Medicare Economic Index (MEI).

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

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12. ESRD Pilot Project Extended for VillageHealth

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2020. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Pilot Project was established to accept and process claims for participating providers who meet the criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage plan. VillageHealth is the only Medicare Advantage plan for which its providers meet the criteria for Medi-Cal secondary payments.

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
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
oth hlth (1)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
dial end (5); oth hlth (1)
Part 1 mcp spec (7); medicare (3)
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13. Microbiology Procedure Code Policy Updates

Effective for dates of service on or after November 1, 2019, do not report (DNR) audits for microbiology procedure codes 87260-87899 are removed.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
General Medicine
Obstetrics
Family PACT
path micro (5)
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14. Updated MSRP Information Reorganized in DME Provider Manual

Durable Medical Equipment provider sections have been reorganized to include, but not limited to, the following:

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
Clinics and Hospitals
Rehabilitation Clinics
dura spe (1–6)
Durable Medical Equipment dura (1, 5–7, 10, 11); dura bil (1–14); dura bil wheel (1, 4, 12, 13); dura cd (1, 2); dura cd ccs (1); dura inf (1–7); dura other (1–34); dura oxy (1–49); dura spe (1–6); dura thp (1–20); dura wheel guide (1)
Orthotics and Prosthetics
Therapies
dura cd (1, 2); dura cd ccs (1); dura spe (1–6)
Pharmacy dura (1, 5–7, 10, 11); dura bil (1–17); dura bil wheel (1, 4, 12, 13); dura cd (1, 2); dura cd ccs (1); dura inf (1–7); dura other (1–34); dura oxy (1–49); dura thp (1–24); dura wheel guide (1)
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15. Medi-Cal Celebrates Medi-Cal Subscription Service Milestone Achievement

The Department of Health Care Services (DHCS) is excited to announce that its Medi-Cal Subscription Service (MCSS) reached and surpassed 20,000 total subscribers as of September 2019.

DHCS first launched its new MCSS in December of 2012, and since that launch, it has witnessed steady growth each year in the volumes of providers and stakeholders who have joined up and officially subscribed to this free and tailored information-based notification service.

Since launching in 2012, DHCS has marketed its MCSS via informational flyers, online articles and at annual Provider Training Seminars throughout California. It’s at these seminars where MCSS representatives directly informed and assisted providers in signing up for the MCSS at the MCSS information booth.

DHCS has received an impressive array of positive and encouraging feedback from countless providers about the MCSS including their individual and satisfied experiences with this service each year.

The MCSS offers an array of provider communication notifications that subscribers can choose to receive including NewsFlash articles, Medi-Cal Update Bulletins and System Status Alerts (SSAs). In addition, each subscriber is able to tailor their individual MCSS experience by selecting only the provider communications and subject matters that interest them and pertain to their Medi-Cal business.

MCSS is a terrific way for providers and stakeholders to save time and ensure that they never miss important program updates and policy changes. The MCSS notifies subscribers the same day whenever the Medi-Cal program releases articles, bulletins and SSAs on the Medi-Cal website.

Providers who have not yet subscribed to the MCSS are encouraged to join this growing community of more than 20,000 subscribers and take full advantage of this free informational service. DHCS invites providers and other interested parties to subscribe today by completing the MCSS Subscriber Form located online.

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16. 2019 Immunization Updates: Flu, HepA, HPV, Measles, CA School Requirements

A new DUR Educational Article titled “2019 Immunization Updates: Flu, HepA, HPV, Measles, CA School Requirements” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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17. 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 October 1, 2019
NDC Labeler Code Contracting Company's Name
14539 HERITAGE PHARMA LABS, INC.
42658 HISUN PHARMACEUTICALS USA, INC.
69230 CAMBER CONSUMER CARE INC.
70382 OCULAR THERAPEUTIX, INC.
71376 IRONSHORE PHARMACEUTICALS, INC.
71894 AVEXIS INC.
72124 CIRCASSIA PHARMACEUTICALS INC.
72152 SAGE THERAPEUTICS
72237 KARYOPHARM THERAPEUTICS
72305 PROVELL PHARMACEUTICALS, LLC.
72578 VIONA PHARMACEUTICALS INC.
72606 CELLTRION USA, INC.
72912 ADLON THERAPEUTICS L.P.
   
Changes, effective October 1, 2019
NDC Labeler Code Contracting Company's Name
59467 HIKMA SPECIALTY USA INC.
   
Terminations, effective October 1, 2019
NDC Labeler Code Contracting Company's Name
13551 FSC LABORATORIES, INC.
61894 SYMPLMED PHARMACEUTICALS
69536 FOUNDATION CONSUMER HEALTHCARE, LLC
69916 TRIBUTE PHARMACEUTICALS US, INC.
69973 HALTON LABORATORIES

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 (6–8, 13, 18–21)
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18. 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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19. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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