Medi-Cal Update

Durable Medical Equipment and Medical Supplies | November 2017 | Bulletin 506

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1. Clarification of Breast Pump Rental and Purchase Policy

When submitting claims for the purchase or rental of lactation management aids such as breast pumps and breast pump kits, providers should follow these guidelines:

HCPCS code E0602 (breast pump, manual, any type):
A Treatment Authorization Request (TAR) is required only if the cumulative cost within the calendar month for the purchase of lactation management aids exceeds $100.

HCPCS code E0603 (breast pump, electric [AC and/or DC], any type):
This is also known as a personal grade (single-user) electric breast pump. A TAR is required only if the cumulative cost within the calendar month for the purchase of lactation management aids exceeds $100.

HCPCS code E0604 (breast pump, hospital grade [AC and/or DC], any type):
This is also known as a hospital grade (multi-user) electric breast pump and is covered for daily rentals only. If there are no other relevant rentals, a TAR is not required until the rental amount exceeds $164 in a 15-month period.

For more information regarding specific TAR criteria and documentation requirements for electric and manual breast pumps, refer to the Durable Medical Equipment (DME): Bill for DME section in the appropriate Part 2 manual.

For more information regarding reimbursement rates for lactation management aids, refer to the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section in the appropriate Part 2 manual.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil dme (21)
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2. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after December 1, 2017, products are added to the List of Contracted Incontinence Absorbent Products.

Effective for dates of service on or after April 1, 2018, products are deleted from the List of Contracted Incontinence Absorbent Products and are no longer reimbursable. The maximum acquisition cost (MAC) for products deleted from the list is no longer guaranteed by the manufacturer.

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3. Updates to the List of Contracted Incontinence Creams and Washes

Effective for dates of service on or after December 1, 2017, products from Medline Industries are added to the List of Contracted Incontinence Creams and Washes.

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4. Seating and Positioning Component Coverage Criteria Update

The seating and positioning component coverage criteria are updated to reflect current policy. Providers may refer to the latest version of the Durable Medical Equipment (DME): Wheelchair and Wheelchair Accessories Guidelines section in the appropriate Part 2 provider manual.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura wheel guide (13–16)
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5. New Modifier ZB Required for HCPCS Code Q5102

Effective retroactively for dates of service on or after July 1, 2016, modifier ZB (Pfizer/Hospira) is required when billing for Inflectra with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZB was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZB (anesthesia [emergency services, healthy patient]) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

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
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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6. New Modifier ZC Required for Billing HCPCS Code Q5102

Effective retroactively for dates of service on or after July 24, 2017, modifier ZC (Merck/Samsung Bioepis) is required when billing for Renflexis with HCPCS code Q5102 (injection, infliximab, biosimilar, 10 mg). Modifier ZC was released through the Centers for Medicare & Medicaid Services (CMS) on September 4, 2015. The CMS modifier should not be confused with the local modifier ZC (anesthesia complicated by extracorporeal circulation) that was discontinued by HIPAA effective for dates of service on or after March 1, 2011.

The new modifier ZC will be available for use January 1, 2018. To avoid claim denials, providers should submit claims for Q5102 with modifier ZC on or after January 1, 2018. Claims submitted for Q5102 without modifier ZC will continue to be accepted.

An Erroneous Payment Correction (EPC) will be generated to accurately adjudicate claims submitted with the CMS modifier ZC with dates of service on or after July 24, 2017. No action is required of providers.

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
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
hcpcs (1); modif app (21, 25)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
hcpcs (1); inject drug i-m (7); modif app (21, 25)
Pharmacy inject drug i-m (7)
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7. Coming Soon: Online PDF RAD and Medi-Cal Financial Summary

Providers will soon be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions Services tab.

Note:  To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

Benefits of PDF RAD
There will be many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments will be made via PDF RADs. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for additional information.

Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246 form). The form, which is expected to be modified in December, is located on the Forms page of the Medi-Cal website (www.medi-cal.ca.gov). The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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8. Medical Supplies Update: Diabetic Tests Strips and Lancets

Effective for dates of service on or after January 1, 2018, OneTouch Verio Test Strips (billing codes 53885027210, 53885027025, 53885027150) are deleted from the List of Contracted Diabetic Test Strips and Lancets and no longer reimbursable.

The product descriptions for Owen Mumford, Inc. Unistik Touch Safety Lancets were updated by removing the “3”. There are no changes to billing or reimbursement with this update.

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9. 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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10. 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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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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