Medi-Cal Update

Durable Medical Equipment and Medical Supplies | June 2018 | Bulletin 513

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1. Phase 3: RTD Generation is Discontinued

The Department of Health Care Services (DHCS) has eliminated the generation of Resubmission Turnaround Documents (RTDs) (Form 65-1). The discontinuation of RTDs will both increase claims processing efficiency and reduce costs.

RTDs were discontinued in multiple phases. The first phase was implemented in November 2017 and the second phase was implemented in February 2018. The third and final phase implemented in May 2018. The new process will deny claims submitted with questionable or missing information instead of generating an RTD. The generation of RTDs has been completely discontinued and providers will no longer receive RTDs. Any current unprocessed RTDs in the providers possession may still be returned to the DHCS Fiscal Intermediary by the due date listed on the RTD and will be processed as normal.

Additional changes to the provider manual 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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2. CCS Service Code Groupings Update

The following codes will be added to the California Children's Services (CCS) Service Code Groupings (SCGs).

Added Codes:
Effective Date Code SCGs
August 1, 2017 CPT-4 codes 81430, 81431 04, 05

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

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 ser (1, 3, 17, 18, 29)
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3. DME for Disabled Parents to Assist with Care for a Child

Effective for dates of service on or after July 1, 2018, Durable Medical Equipment (DME) may be authorized with an approved Treatment Authorization Request (TAR) to assist disabled parents, stepparents, foster parents and legal guardians care for their child. Submitted TARs must document that the DME item is medically necessary for the recipient to care for their child, and has been prescribed by a physician.

When billing, providers must submit claims using HCPCS code A9999 (miscellaneous DME supply or accessory, not otherwise specified), ICD-10-CM diagnosis code Z73.6 (limitation of activities due to disability) and modifier SC.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (1); dura bil dme (1, 11)
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4. Power Wheelchair Nonstandard Seat Frames are Not Separately Reimbursable

Effective for dates of service on or after July 1, 2018, HCPCS codes for nonstandard seat frames for power wheelchairs (E2340 – E2343) are not separately reimbursable when provided within the same month of service as the Group 1, 2, 3 or 4 power wheelchair base, unless the Group 3 or 4 power wheelchair base has a sling/solid seat/back.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil wheel (19, 20)
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5. All Other Methods Must be Exhausted Before a Power Seat Elevator is Covered

Effective for dates of service on or after July 1, 2018, power seat elevators are covered only when there is documentation that other methods to achieve mobility related activities of daily living (ADL) or instrumental activities of daily living (IADL) without a power seat elevator have been exhausted.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura wheel guide (17)
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6. Seating and Positioning Component Coverage Criteria Removed or Modified

Effective for dates of service on or after July 1, 2018, certain wheelchair medical necessity criteria and seating and positioning component coverage criteria are removed or modified. These changes are made to reflect stakeholder input provided in response to a previous Medi-Cal Update.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura wheel guide (8, 13, 15, 16)
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7. Updates to the List of Enteral Nutrition Products and Policy Additions

Effective for dates of service on or after July 1, 2018, products by the following manufacturers are added to the List of Enteral Nutrition Products:

The manufacturers guarantee providers can purchase the listed products at or below the maximum acquisition cost (MAC), upon request, for dispensing to Medi-Cal fee-for-service outpatient recipients. Refer to the Enteral Nutrition Products section of the appropriate Part 2 manual for the MAC price suppliers’ telephone numbers.

Note:

Listing of a product is not a guarantee of its availability. The product number approved on an authorization must be the same product number dispensed to the recipient and claimed for reimbursement by the provider.

Effective for dates of service on or after July 1, 2018, Vitaflo is discontinuing the following Flavor Pac products and they will no longer be reimbursable:

Product Label Name Billing Number
Flavor Pac Black Currant 50600-0541-59
Flavor Pac Lemon 50600-0540-98
Flavor Pac Orange 50600-0541-11
Flavor Pac Raspberry 50600-0541-35
Flavor Pac Tropical 50600-0541-73

Vitaflo has also removed the Universal Product Code (UPC) item number for the specialized product, Renastart, and updated the case number to 812539021490.

Medi-Cal recipients denied enteral nutrition products who believe the denial was in error may ask for a state hearing by contacting the California Department of Social Services at 1-800-743-8525 or 1-855-795-0634 or by sending a written request to:

  California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA  94244-2430

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (17)
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8. Contracted Incontinence Absorbent Product Updates and Policy Reminders

Effective for dates of service on or after June 1, 2018, one protective underwear product from First Quality Products, Inc. is added to the List of Contracted Incontinence Absorbent Products and the HCPCS code for one disposable underpad product from Medline Industries, Inc. is changed.

In addition, the item numbers for two products from Cardinal Health 200, LLC are changed.

Effective for dates of service on or after August 1, 2018, certain products from Cardinal Health 200, LLC, Drylock Technologies, Ltd., First Quality Products, Inc. and San Pablo Commercial Corporation 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.

The Department of Health Care Services (DHCS) reminds providers that only incontinence medical supplies ordered by a physician are reimbursable, pursuant to Code of Federal Regulations (CFR), Title 42, Section 440.70. In addition, a recipient’s need for incontinence medical supplies must be reviewed by a physician annually.

Providers are also reminded that incontinence products supplied as refills are reimbursable if the product remains reasonable and necessary and the existing supply is nearly exhausted. To ensure that refilled incontinence medical supplies remain reasonable and necessary, providers should contact the recipient prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the recipient.

In addition, providers are reminded that selecting the appropriate product size to accommodate the recipient’s body type and mass may optimize a better fit and reduce leakage, thereby decreasing the number of product changes. A proper fit may also contribute to the comfort of recipients and the prevention of excess product folds that may cause pressure.

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9. Pharmacist Furnishing of Medications under Statewide Protocol

All medications authorized by Senate Bill 493 and subsequent amendments of the Business and Professions Code (B&P Code), Section 4052 are reimbursable by the Medi-Cal program for pharmacy claims, including drug costs and dispensing fees, when furnished by pharmacists within their scope of practice. Pharmacists do not need to be enrolled as Ordering, Referring and Prescribing (ORP) providers when they are the prescriber on record using their own National Provider Identifier (NPI) for these claims.

The following medication classes are currently exempt from ORP enrollment for reimbursement of pharmacy claims, including drug costs and the dispensing fees, when furnished by pharmacists within their scope of practice:

When the Department of Health Care Services (DHCS) implements reimbursement for the professional services associated with furnishing the above medication classes, as authorized under Assembly Bill 1114 and Welfare and Institutions Code (W&I Code), Section 4132.968, the pharmacist providing such services must be an approved ORP provider. Additionally, all pharmacists furnishing medications under collaborative practice agreements according to B&P Code, Sections 4052.1, 4052.2 and 4052.6 will be required to be ORP providers in order for pharmacy claims to be reimbursed. Therefore, DHCS encourages all pharmacists to become ORP providers with the Medi-Cal program.

Providers should refer to the Ordering, Referring and Prescribing (ORP) web page on the Medi-Cal website for more information.

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10. Rate Update for Preventive Medicine Evaluation and Management Codes

Effective retroactively for dates of service on or after June 1, 2017, the reimbursement rates for initial and periodic comprehensive medicine evaluation and management for recipients 18-39 years of age (CPT-4 codes 99385 and 99395) are established.

A list of current rates can be found on the Medi-Cal Rates page of the Medi-Cal website.

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11. Diagnosis Restrictions Removed for Select Blood Pressure Equipment

Effective for dates of service on or after July 1, 2018, HCPCS codes A4660 (sphygmomanometer/blood pressure apparatus with cuff and stethoscope) and A4663 (blood pressure cuff only) do not require documentation for reimbursement except for pricing information. These codes may be billed with any ICD-10-CM diagnosis code that justifies medical necessity.

Additionally, these codes are for purchase only. If these codes are billed with modifier RR (rental), the claim will be denied.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil dme (24)
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12. Reminder: VeriFone VX 520 POS Device to Decommission in July 2018

In July 2018, the VeriFone VX 520 Point of Service (POS) device will be decommissioned. Transactions from these devices will no longer be accepted or processed after decommission. A final notification letter will be mailed out instructing providers to return the devices. Providers may contact the POS Help Desk at 1-800-541-5555 (option 5, followed by option 6) for information about the decommission and to learn about available alternative options.

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13. July 2018 Medi-Cal Provider Seminar

The July Medi-Cal provider seminar is scheduled for July 17 – 18, 2018, at the Almansor Court in Alhambra, 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 DHCS 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 July 3, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 3, 2018, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks 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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14. A New Way to Subscribe – Contact Medi-Cal Subscription Service Representatives

Medi-Cal is committed to keeping you up-to-date on the latest Medi-Cal news and policy updates.

The Medi-Cal Subscription Service (MCSS) is a free service that provides subscribers with personalized email notifications for urgent, high-impact announcements and monthly news/policy updates as they post to the Medi-Cal website.

Providers can now contact MCSS representatives directly at MCSSCalifornia@conduent.com to subscribe and for assistance with managing subscriptions. Subscribing is simple and free!

If you have not yet subscribed to MCSS, Medi-Cal encourages you to utilize one of the following two methods to subscribe.

To subscribe by email:

  1. Download the linked MCSS Subscriber Form

  2. Enter your name, email address, ZIP code and subscriber type in the appropriate fields

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Attach your completed form to an email and send to MCSSCalifornia@conduent.com

To subscribe online:

  1. Go to the MCSS Subscriber Form page on the Medi-Cal website

  2. Enter your email address and ZIP code, and select a subscriber type from the drop-down menu

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

  4. Click “Subscribe Now” at the bottom of the page

After the form has been received, 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, visit the MCSS Help page.

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15. 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.

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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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