Medi-Cal Update

Clinics and Hospitals | November 2019 | Bulletin 542

Print Medi-Cal Update
 

1. Notice: Obsolete CHDP Information Retired

After November 2019, Child Health and Disability Prevention (CHDP) program information is incorporated into several Medi-Cal provider manuals, including the General Medicine and Clinics and Hospitals manuals.

CHDP Manual Discontinued
The CHDP Provider Manual primarily contained instructions for billing non-HIPAA compliant local codes on the Confidential Screening/Billing Report (PM 160) claim form. This information is outdated and is discontinued.

New EPSDT/CHDP Provider Manual Sections
CHDP program information may now be found in three new EPSDT/CHDP provider manual sections, as follows:

Title Content
EPSDT/CHDP Most of the CHDP policy moved from the obsolete CHDP Provider Manual is captured in this section, including information about:

CHDP program background, provider enrollment, provider responsibilities, recipient eligibility, components of health assessments and immunizations. There is some billing instruction but most of the billing is according to standard Medi-Cal practices as explained in the provider manual billing sections.

The Part 2 Medi-Cal manual section, Child Health and Disability Prevention (CHDP) Program, is discontinued, with select information incorporated into this new EPSDT/CHDP section.
EPSDT/CHDP: Gateway This section contains information from the former Gateway and Gateway Transactions Overview sections.
EPSDT/CHDP: School-Based Services Primarily carried over from CHDP Provider Manual section, CHDP Transition to National Standards: School-Based Services.

The three EPSDT/CHDP sections do not contain new policy.

Note:

Providers were notified in a previous NewsFlash titled “Transition of CHDP Information to EPSDT/CHDP Sections” that providers wishing to retain CHDP Provider Manual content for future research should save the manual sections to their own computers. After November 30, 2019, there is no assurance the former CHDP Provider Manual sections will be available on the Medi-Cal website.

CHDP More Closely Aligned with EPSDT Section in Medi-Cal Manual
In California, CHDP administers the Early and Periodic screening components of the federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for individuals under the age of 21. The CHDP program information is now aligned with the EPSDT section of the Medi-Cal provider manual under EPSDT/CHDP.

Finding EPSDT/CHDP Information
The EPSDT/CHDP sections will publish in the following Part 2, Medi-Cal provider manuals. Additionally, EPSDT/CHDP articles will publish in the monthly bulletin that corresponds to each of the following manuals:

CHDP Updates Continue
The Department of Health Care Services (DHCS) is working diligently to update CHDP information in provider manuals and on both the Medi-Cal and DHCS websites. Because both the DHCS and Medi-Cal websites have or will undergo reorganization, updating efforts will continue for some time.

Providers are encouraged to watch for EPSDT/CHDP updates in the NewsFlash area on the Medi-Cal website and subscribe to MCSS to receive timely notifications related to CHDP by completing the MCSS Subscriber Form.

CHDP Gateway Internet User Guide
Recent updates were made to the CHDP Gateway Internet Step-by-Step User Guide unrelated to this process. Providers are encouraged to review the guide for current information regarding CHDP Gateway transactions.

Questions
Providers with questions may call the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, except holidays.

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

Provider Manual(s) Page(s) Updated
Part 1 check (1); cmc enroll (1–7, 12); elect (1); prog (4); prov guide (11)
Acupuncture
Chiropractic
cms comp (21)
Audiology and Hearing Aids
Obstetrics
Orthotics and Prosthetics
cal child bil guide (1); cms comp (21); epsdt chdp (1–31); epsdt chdp gate (1–13)
Chronic Dialysis Clinics
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Rehabilitation Clinics
cal child bil guide (1)
Clinics and Hospitals cal child bil guide (1); epsdt chdp (1–31); epsdt chdp gate (1–13); epsdt chdp school (1–6); spec (6)
Durable Medical Equipment
Medical Transportation
Pharmacy
Therapies
cal child bil guide (1); cms comp (21)
General Medicine cal child bil guide (1); cms comp (21); epsdt chdp (1–31); epsdt chdp gate (1–13); epsdt chdp school (1–6); spec (6)
Psychological Services cal child bil guide (1); cms comp (21); epsdt chdp (1–31); epsdt chdp gate (1–13); spec (6)
Vision Care cal child bil guide (1); cms comp vc (11); epsdt chdp (1–31); epsdt chdp gate (1–13); pia (1); rates max eye app (2)
Print Article | Return to Top
 

2. DME and Medical Supplies for Recipients Impacted by the State of Emergency

Update: Replacement Durable Medical Equipment (DME) and Medical Supplies for Recipients Impacted by Fires and Extreme Weather Conditions or Public Safety Power Shutoff

On October 28, 2019, in response to the Governor’s recent proclamation of a statewide state of emergency due to the risk of wildfires, the Department of Health Care Services (DHCS) issued guidance for dispensing replacement medication(s) to recipients impacted by fires and extreme fire weather conditions or public safety power shutoff. This article provides additional guidance for dispensing DME and medical supplies.

Providers are instructed to incorporate the statement “Patient impacted by fires and extreme fire weather conditions or public safety power shutoff.” within the Miscellaneous Information field on the Treatment Authorization Requests (TAR) for DME, medical supplies or situations requiring a TAR.

DME and medical supply providers must provide requested equipment or supplies immediately or, for items not in stock, as soon as possible, if the need to dispense DME or medical supplies is related to the recipient’s displacement or subjection to fires and extreme fire weather conditions or public safety power shutoff. Providers must not have the recipient return after receiving TAR approval. The need for a TAR should not negatively affect the decision to provide DME or medical supplies immediately or as soon as possible, and the TAR can be submitted retroactively. It is imperative that the impacted recipient receive the DME or medical supply in a timely manner to facilitate compliance and assist the recipient to perform activities of daily living.

TARs for new or replacement DME or medical supplies will be automatically approved if the TAR indicates that the recipient is impacted by fire or by power shutoffs, and the provider will be paid for the claim for the DME or medical supply. The negative impact of the fire or power shutoff, alone, will meet the criteria of medical necessity.

Providers are encouraged to monitor the Medi-Cal website for future updates. Questions regarding this notice may be directed to the Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, except holidays.

Print Article | Return to Top
 

3. New ICD Requirement for Spinal Canal Ultrasound

Effective for dates of service on or after December 1, 2019, CPT code 76800 (ultrasound, spinal canal and contents) is reimbursable when billed in conjunction with ICD-10-CM diagnosis code Q82.6 (congenital sacral dimple).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia ult (2)
Print Article | Return to Top
 

4. Updates to Clinic Dispensing of Internal (Female) Condoms

Effective for dates of service on or after May 1, 2019, HCPCS code A4268 (contraceptive supply, condom, female, each) may be billed separately at the rate of $2.50 per unit for the Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) programs. The clinic dispensing fee is 10 percent of the subtotal billed. In addition, the dispensing limit for code A4268 is up to 12 units per claim and up to 24 units in a 90-day period.

An Erroneous Payment Correction (EPC) will 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
fam planning (5, 13, 14)
Family PACT ben grid (24); clinic (4, 8, 10); drug (3, 5); drug onsite (1)
Print Article | Return to Top
 

5. Policy for Medical Supply Billing Codes Updated to DME Supply Billing Codes

Effective for dates of service on or after February 1, 2020, the following medical supply billing codes are updated to Durable Medical Equipment (DME) supply billing codes: HCPCS codes A4222, A4230 – A4232, A4483, A7002 – A7004, A7006 – A7008, A7010, A7012, A7013, A7016, B4035 and S8186. Note that codes A4230 – A4232 and A7008 are not benefits.

These HCPCS codes that describe items used in the operation of DME will no longer be medical supply codes on the List of Medical Supplies Billing Codes, Units and Quantity Limits. These HCPCS codes must be billed as DME supply codes.

Updates to Medical Supply Codes
Effective for dates of service on or after February 1, 2020, medical supply HCPCS codes are updated as follows:

A4223

Infusion supplies not used with external infusion pump, per cassette or bag. Use to bill all necessary supplies that are not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to administrative sets and syringes, tubing, extension tubing, connecting devices and port caps) for the administration, without a pump, of non-insulin drugs.

Bill one (1) quantity unit per each administrative/infusion set/kit or per each separate item (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 30 units per 27-day period require authorization.

Documentation of product cost (an invoice, manufacturer’s catalog page or price list) is required as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Refer to DME supply HCPCS code A4222 for infusion supplies used with an external infusion pump.

B4034 Enteral feeding supplies; syringe fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by syringe and maintain the feeding site.
B4036

Enteral feeding supplies; gravity fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by gravity and maintain the feeding site.

For claims using HCPCS code B4034 and B4036, bill one (1) quantity unit per each administrative/supply set/kit or per each separate item, (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 31 units per 27-day period require authorization.

HCPCS code B4034 and B4036 require documentation of product cost (an invoice, manufacturer’s catalog page or price list) as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Note:

HCPCS code B4035, enteral feeding supplies (pump fed), is updated to a DME supply code.

Effective for dates of service on or after February 1, 2020, HCPCS codes B9998, B9999 and S1015 will be end-dated. Providers must bill the items using the following codes:

Updates to DME Supply Codes
HCPCS codes A4230 – A4232 and A7008 are no longer benefits. The table below specifies policy for new DME supply codes A4483, A7002 – A7004, A7006, A7007, A7010, A7012, A7013, A7016, B4035 and S8186. In addition, policy for codes A4222, A4224, A4225 and E0574 is as follows.


HCPCS Code
Description Taxable/Non-Taxable Frequency Limit, Any Provider
A4222 * + Infusion supplies for external drug infusion pump, per cassette or bag Non-taxable --
A4224 * + ^ Supplies for maintenance of insulin infusion catheter, per week Non-taxable 1 per week
A4225 * + ^ Supplies for external insulin infusion pump, syringe type cartridge, sterile, each Non-taxable 15 per month
A4483 * + ^ Moisture exchanger, disposable, for use with invasive mechanical ventilation Non-taxable (no change) 31 per month
A7002 * + Tubing, used with suction pump, each Non-taxable 4 per month
A7003 * + Administration set, with small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7004 * + Small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7006 * + Administration set, with small volume filtered pneumatic nebulizer Taxable (no change) 1 per month
A7007 * + Large volume nebulizer, disposable, unfilled, used with aerosol compressor Taxable (no change) 1 in 2 months
A7010 * + Corrugated tubing, disposable, used with large volume nebulizer, 100 ft Taxable (no change) 1 in 2 months
A7012 * + Water collection device, used with large volume nebulizer Taxable (no change) 2 per month
A7013 * + Filter, disposable, used with aerosol compressor or ultrasonic generator Taxable (no change) 2 per month
A7016 * + Dome and mouthpiece, used with small volume ultrasonic nebulizer Taxable (no change) 2 per year
B4035 * + ^ Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape Taxable 31 per month
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer Taxable (no change) 1 in 5 years
S8186 * + Swivel adaptor Non-taxable (no change) 2 in 12 months

*  This code must be billed with modifier NU. Modifiers RB and RR are not allowed.
+  This code is for patient-owned equipment.
^  This code must be billed using the “from-through” (block-billing) method when billing for more than one day of service.

HCPCS code A7016 may be reimbursed only when used with code E0574. Authorization for rental of code E0574 may be granted in increments of up to three months, both for the initial authorization and for reauthorization. Authorization for purchase of code E0574 may be granted for one device every five years. Claims for code E0574 must include modifier NU, RR or RB.

HCPCS code S8186 is not covered by Medicare and should be billed to Medi-Cal directly.

HCPCS codes A4224 and A4225 are reimbursable under the Presumptive Eligibility for Pregnant Women (PE4PW) program.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (1)
Audiology and Hearing Aids medi non hcp (1); tax (6–8, 10, 12, 13)
Durable Medical Equipment dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); tax (6–8, 10, 12, 13)
General Medicine
Obstetrics
Clinics and Hospitals
medi non hcp (1); presum bill (12)
Orthotics and Prosthetics dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1); tax (6–8, 10, 12, 13)
Pharmacy dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); presum bill (12); tax (6–8, 10, 12, 13)
Therapies dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1)
Print Article | Return to Top
 

6. Remove Frequency Limits for Select Intrauterine Devices and Contraceptive Implant

Effective retroactively for dates of service on or after January 1, 2016, the frequency limit of HCPCS code J7307 (etonogestrel [contraceptive] implant system, including implant and supplies) is removed. Effective retroactively for dates of service on or after October 1, 2016, the frequency limits of HCPCS codes J7297 (levonorgestrel-releasing intrauterine contraceptive system, [liletta], 52 mg) and J7298 (levonorgestrel-releasing intrauterine contraceptive system, [mirena], 52 mg) are removed.

No action is required of providers. 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
Obstetrics
fam planning (9, 11)
Family PACT ben fam (23, 30); ben grid (24)
Print Article | Return to Top
 

7. Maximum Dose Restriction for Acyclovir Injection Removed

Effective for dates of service on or after December 1, 2019, the maximum dose restriction of 300 units for HCPCS code J0133 (injection, acyclovir, 5 mg) has been removed.

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 drug a-d (3)
Print Article | Return to Top
 

8. Update to Buprenorphine ICD-10-CM Diagnosis Code Requirement

Effective for dates of service on or after July 1, 2019, HCPCS code J0570 (buprenorphine implant, 74.2 mg) cannot be billed with ICD-10-CM diagnosis code F11.23 (opioid dependence with withdrawal) for reimbursement.

Print Article | Return to Top
 

9. 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 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.

Print Article | Return to Top
 

10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Print Article | Return to Top


Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.