Medi-Cal Update

Durable Medical Equipment and Medical Supplies | October 2017 | Bulletin 505

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1. Revisions to 2017 CPT-4/HCPCS Annual Update

A previously published Medi-Cal Update added, changed and deleted CPT-4 and HCPCS codes for the 2017 annual update, effective October 1, 2017. The following policy has been revised:

Medicine
CPT-4 code 92242 (fluorescein angiography and indocyanine-green angiography [includes multiframe imaging] performed at the same patient encounter with interpretation and report, unilateral or bilateral) is split-billable and modifiers TC and 26 are required. Modifier 22 is allowable. Modifiers SA, SB and U7 are not allowable.

The Place of Service restrictions for CPT-4 code 94060 (bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) are removed.

CPT-4 codes 99151 (moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age), 99152 (…initial 15 minutes of intraservice time, patient age 5 years or older) and 99153 (…each additional 15 minutes of intraservice time) are exempt from the modifier 51 reimbursement cutback.

Modifiers SA and SB are allowable for CPT-4 code 99156 (moderate sedation services provided by a physician or other qualified health care professional other than the physician or qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older) and HCPCS code G0500 (moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older).

CPT-4 code 99157 (moderate sedation services provided by a physician or other qualified health care professional other than the physician or qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes intraservice time) is exempt from the modifier 51 reimbursement cutback and modifiers SA and SB are allowable.

Radiology
CPT-4 code 77789 (surface application of low dose rate radionuclide source) is split-billable and modifiers TC and 26 are allowable.

HCPCS codes A9587 (gallium ga-68, dotatate, diagnostic, 0.1 millicurie) and A9588 (fluciclovine f-18, diagnostic, 1 millicurie) include “millicuries” in their descriptors and reimbursement is allowed as per their descriptors. A Treatment Authorization Request (TAR) override is allowed.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics modif used (6, 11)
Clinics and Hospitals General Medicine modif used (6, 11); non ph (8, 21, 22); ophthal (2, 3); radi nuc (6, 7); radi onc (2–4); respir (4); surg bil mod (8); tar and non cd3 (7)
Durable Medical Equipment
Therapies
respir (4)
Inpatient Services tar and non cd3 (7)
Obstetrics modif used (6, 11); non ph (8, 21, 22); radi nuc (6, 7); radi onc (2–4); surg bil mod (8); tar and non cd3 (7)
Rehabilitation Clinics modif used (6, 11); non ph (8, 21, 22); respir (4)
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2. RTD Generation to be Discontinued in Multiple Phases

The Department of Health Care Services (DHCS) will be phasing out the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1) over the next 12 months. The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs will be discontinued in multiple phases. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. As DHCS transitions from the use of RTDs to claim denials, providers can expect to receive fewer RTDs. When the project is completed, the use of RTDs will be completely discontinued.

The implementation of each RTD phase-out period will be announced in a future monthly bulletin. Providers are encouraged to routinely check the Medi-Cal website for more information.

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4. Boulder City Added as Border City for Specific Field Offices and Services

Effective immediately, Boulder City, Nevada is added as a Border City for the following Medi-Cal Field Offices and their respective services:

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
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
tar field (4, 8, 9, 11)
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5. Resubmission of Claims Denied for Certain Medicare Non-Covered Services

The Department of Health Care Services (DHCS) identified a claims processing issue affecting certain claims billed with the following medical supply billing codes.


A4206 – A4209
A6021 A6266
A4212 A6022 A6402 – A6404
A4213 A6154 A6407
A4215 A6196 A6410
A4223 A6197 A6411
A4244 – A4248 A6199 A6442 – A6447
A4461 A6203 – A6224 A6453 – A6455
A4657 A6228 – A6248 A6457
A4927 A6251 – A6259 T4537
A4930 – A4932 A6261  
A6010 A6262  

Providers may resubmit claims that meet all of the following criteria:

Providers may resubmit claims adhering to the criteria above during a six-month period beginning October 16, 2017, and ending April 15, 2018.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (5); medi non hcp (3)
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
medi non hcp (3)
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6. Updates to Medical Supplies Billing Codes, Units and Quantity Limits

Effective for dates of service on or after April 1, 2017, the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet is updated. Wound care claims billed with HCPCS codes A6021 (collagen dressing, sterile, size 16 sq. in. or less, each) and A6022 (collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each) are no longer limited to four Endoform dressings. Products billed with HCPCS codes A6021 and A6022 are limited to 10 dressings per wound per 27-day period, up to 90-day duration of therapy.

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7. Medical Supplies Updates: Wound Care Advanced Dressings

Effective for dates of service on or after October 1, 2017, the List of Contracted Wound Care Advanced Dressings is updated. Dressings by Molnlycke are added to the list and the end dates are removed for other dressings by Molnlycke and will be reimbursable for the following HCPCS codes:

Code Description
A6206 Contact layer, sterile, 16 sq. in. or less, each dressing
A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing
A6208 Contact layer, sterile, more than 48 sq. in., each dressing
A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing
A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing
A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing
A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing
A6257 Transparent film, sterile, 16 sq. in. or less, each dressing
A6258 Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing
A6259 Transparent film, sterile, more than 48 sq. in., each dressing

Also effective for dates of service on or after October 1, 2017, L & R USA Inc products are added to the List of Contracted Wound Care Advanced Dressings for HCPCS codes A6209, A6212 and A6213.

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8. 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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9. National Correct Coding Initiative Quarterly Update for October 2017

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative 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 October 1, 2017.

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

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