Medi-Cal Update

Durable Medical Equipment and Medical Supplies | August 2017 | Bulletin 503

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

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2. 2017 CPT-4/HCPCS Annual Update: Policy Updates

The 2017 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2017 CPT-4/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 October 1, 2017. Please refer to the 2017 CPT-4 and HCPCS Level II code books for complete descriptions of these codes. Manual replacement pages reflecting these changes will be released in a future Medi-Cal Update.

Additionally, the 2017 CPT-4 codebook was updated to allow separate reimbursement for moderate (conscious) sedation for multiple codes that had previously included moderate (conscious) sedation as an inherent part of providing the procedure. Please refer to the 2017 CPT-4 codebook for instructions on how to bill for this service with other codes.

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3. Medical Supplies: Sterile Needles (HCPCS A4125) Restricted to Contract List

Effective for dates of service on or after November 1, 2017, claims billed with HCPCS code A4215 (needles, sterile, any size, each) will be restricted to products on the new List of Contracted Sterile Needles (HCPCS A4215) spreadsheet. These products will no longer require documentation of the product cost (an invoice, manufacturer catalog page or price list), as an attachment to the claim for reimbursement.

DHCS recently signed a maximum acquisition cost (MAC) agreement with RGH Enterprises, Inc. (dba Independence Medical) for products that meet the HCPCS code A4215 description, including pen needles used in conjunction with injection pens to deliver insulin. The MAC agreement is a guarantee from Independence Medical that any Medi-Cal provider can purchase the products upon request at or below the MAC for dispensing to Medi-Cal fee-for-service outpatient recipients.

Effective for dates of service on or after November 1, 2017, claims billed with HCPCS code A4215 will require the Universal Product Number (UPN) and UPN Qualifier as published on the list.

The maximum allowable product cost (MAPC) for the sterile needles on the list will be the same as the contracted MAC as published on the list. The maximum amount reimbursed to providers will be the lesser of:

Reimbursement for sterile needles is subject to the Upper Billing Limit defined in California Code of Regulations (CCR), Title 22, Section 51008.1. The UPN on the claim billed must be the exact UPN for the product dispensed. Listing of contracted products does not guarantee the product's availability.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1)
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4. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically
  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 278 transactions
    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 278 transactions

Registered providers, clearinghouses or Managed Care Plans can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

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 (1, 12); genetic (4, 5)
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5. Enteral Nutrition Product List Update

Effective for dates of service on or after August 1, 2017, Polycal, unflavored, 400g can, will be reimbursable with an approved authorization on the Medi-Cal Fee-For-Service List of Enteral Nutrition Products. This product, manufactured by Nutricia North America, is a powdered concentrated source of energy and is available as a specialized enteral nutrition product. Please refer to the List of Enteral Nutrition Products for billing and UPC numbers. The EAC price is 0.0214.

The amount reimbursed to providers for contracted enteral nutrition products is the estimated acquisition cost (EAC) listed on the List of Enteral Nutrition Products spreadsheet plus a 23 percent markup.

Listing items is not a guarantee of an item's availability. Product numbers approved on an authorization must be the product number dispensed to the beneficiary and be the product number claimed for reimbursement by the provider. Billing quantities must be appropriate for the product size (quantity) dispensed and product description on the List of Enteral Nutrition Products spreadsheet. Rounding quantities on claims for enteral nutrition products is not permitted.

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6. Face-to-Face Encounter Required for DME Prescription

Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to allow reimbursement to providers only for Durable Medical Equipment (DME) items that are signed for by a physician in either written or electronic format. Additionally, a face-to-face encounter administered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, related to the primary reason the recipient requires the DME item, is also required. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (1, 4, 5); dura bil dme (3, 9, 10, 14, 22, 25); dura bil oxy (12); dura bil thp (11)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (3, 12)
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7. September 2017 Medi-Cal Provider Seminar

The September Medi-Cal provider seminar is scheduled for September 26 – 27, 2017, at the Ontario Convention Center in Ontario, California. Providers can access a class schedule for the seminar by visiting the Provider Training 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 DHCS Fiscal Intermediary 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 September 12, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After September 12, 2017, 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 regional representative.

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

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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