Medi-Cal Update

Chronic Dialysis Clinics | March 2019 | Bulletin 534

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1. Medi-Cal Website to Get an Updated Look and Feel

This spring, the Medi-Cal website will have an updated look and feel. All of the current content will be migrated to the new website and will be easier to access.

Benefits:

Access to transactions and the Medi-Cal Learning Portal will remain the same.

As the update of the website progresses, the Department of Health Care Services (DHCS) will provide updates on the Medi-Cal website.

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2. Claims for Tetanus and Diphtheria Vaccine Erroneously Denied

For dates of service on or after September 1, 2013, claims for CPT code 90714 (tetanus and diphtheria toxoids adsorbed [Td], preservative free, when administered to individuals 7 years or older, for intramuscular use) for recipients 19 years of age and older have erroneously denied.

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

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3. Updates to Policy for Intravitreal Implants

Effective for dates of service on or after October 1, 2016, HCPCS code J7313 (injection, fluocinolone acetonide, intravitreal implant, 0.01 mg), is reimbursable for patients 18 years of age and older. An approved Treatment Authorization Request (TAR) is required for reimbursement. The TAR must include clinical documentation of the following:

Modifier LT or RT is required on the claim.

An Erroneous Payment Correction will be initiated to reprocess affected claims for HCPCS code J7313. No action is required of providers.

Additionally, the TAR criteria for HCPCS code J7311 (fluocinolone acetonide, intravitreal implant) is expanded upon. The TAR must include clinical documentation of the following:

Modifier LT or RT is required on the claim. Patients must be 12 years of age and older for reimbursement.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (6)
Clinics and Hospitals
General Medicine
inject cd list (6); ophthal (15, 16)
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4. Medi-Cal Benefit Rebinyn Billable Under New HCPCS Code

Effective for dates of service on or after April 1, 2019, blood factor Rebinyn is billable under HCPCS code J7203 (Injection Factor IX, [antihemophilic factor, recombinant], glycopegylated, [Rebinyn], 1 IU). A Treatment Authorization Request (TAR) is required when billing code J7203.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
blood (3)
Clinics and Hospitals
General Medicine
blood (3); non ph (13, 26)
Obstetrics
Rehabilitation Clinics
non ph (13, 26)
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5. Epoetin Beta ESRD Therapy a Medi-Cal Benefit

Effective for dates of service on or after April 1, 2019, HCPCS code J0887 (injection, epoetin beta, 1 microgram [for ESRD on dialysis]) is a Medi-Cal benefit for patients 5 years of age and older. An approved Treatment Authorization Request (TAR) is required for reimbursement and must include documentation that demonstrates the following:

ICD-10-CM diagnosis code N18.6 (End stage renal disease) must be included on the claim for reimbursement.

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 cd list (6); inject drug e-h (21–23)
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6. Modifiers Override Medical Justification Requirement

Effective for dates of service on or after March 1, 2019, billing CPT codes 92002 – 92014 (general ophthalmological services) and 99201 – 99499 (Evaluation and Management [E&M] services) with modifier 24, 25 or 57 overrides the requirement of documenting medical justification when billed in conjunction with a surgical procedure as follows:

Modifier Description Application
24 Unrelated E&M service by the same physician or other qualified health care professional during a postoperative period Minor (follow-up days of zero or 10) or major surgical procedures (follow-up days of 90)
25 Significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service Minor (follow-up days of zero or 10) or major surgical procedures (follow-up days of 90)
57 Decision for surgery (major surgery only, day before or day of procedure) Major surgical procedures only (follow-up days of 90)

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
Hospice Care Program
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (2, 3)
Chronic Dialysis Clinics
Rehabilitation Clinics
modif app (2, 3); modif used (3, 5, 11)
Clinics and Hospitals
General Medicine
Obstetrics
eval (2); modif app (2, 3); modif used (3, 5, 11); surg bil mod (9)
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7. Updated Guidance for DRG Reimbursed Claims with More Than 22 Line Items

Effective retroactively for dates of service on or after June 6, 2014, diagnosis-related group (DRG) reimbursed claims that contain more than 22 lines should be divided across multiple pages and assigned a unique Claim Control Number (CCN) for each page. A Claims Inquiry Form (CIF) void must be submitted for all CCNs associated with the stay from admit through discharge to recoup any payments prior to the resubmission of a corrected claim. If all reimbursed CCNs are not voided, including CCNs with zero payment, this can cause the resubmitted claim to deny. A reimbursed claim that is not voided causes the new claim to be a duplicate of the previously reimbursed claim (Remittance Advice Details [RAD] code 010).

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

Provider Manual(s) Page(s) Updated
Part 2 cif co (4, 5)
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8. National Correct Coding Initiative Quarterly Update for April 2019

The Centers for Medicare & Medicaid Services (CMS) are scheduled to routinely release the quarterly National Correct Coding Initiative (NCCI) in Medicaid payment policy updates. These mandatory national edits will be incorporated into the Medi-Cal claims processing system and will be effective for dates of service on or after April 1, 2019.

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

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9. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Terminations, effective February 8, 2019
NDC Labeler Code Contracting Company's Name
59212 CONCORDIA PHARMACEUTICALS, 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 (13)
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10. April 2019 Medi-Cal Provider Seminar

The April Medi-Cal Provider Seminar is scheduled for April 17, 2019, at the Red Lion Hotel Redding in Redding, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by April 3, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 3, 2019, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web page of the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a representative.

Providers are encouraged to bookmark the Provider Training web page and refer to it often for current seminar information.

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11. 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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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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