Medi-Cal Update

Durable Medical Equipment and Medical Supplies | November 2018 | Bulletin 518

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1. Disposable Insulin Delivery System Code Is Now a Medi-Cal DME Code

Effective for dates of service on or after September 1, 2018, HCPCS code A9274 (external ambulatory insulin delivery system, disposable, each, includes all supplies and accessories) is updated to a Durable Medical Equipment (DME) code when billing Medi-Cal directly. There are no changes regarding the submission of Treatment Authorization Requests (TARs) or claims.

The Centers for Medicare & Medicaid Services has defined disposable insulin delivery systems (items that meet HCPCS code A9274 description) as coverable under Medicare Part D. Medi-Cal does not reimburse for any items coverable under Medicare Part D for Medicare/Medi-Cal dual eligible and Part D-eligible recipients. Providers must submit claims for disposable insulin delivery systems to the Prescription Drug Plan or Medicare Advantage-Prescription Drug Plan in which the recipient is enrolled.

The Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet is updated to reflect this change.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (2)
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2. Policy Clarification for Reimbursement of Insulin Pumps

Durable insulin pumps are reimbursed with HCPCS code E0784 (external ambulatory infusion pump, insulin) for the treatment of insulin-dependent (Type I) diabetes mellitus. Rental reimbursement is at a monthly rate and requires authorization.

Patch and/or disposable insulin pumps are not a covered Medi-Cal benefit.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil inf (3)
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3. New Criteria Requirement for CPAP and Bi-PAP Equipment

Effective for dates of service on or after December 1, 2018, there are new criteria requirements for Continuous Positive Airway Pressure (CPAP) and Bi-Level Positive Airway Pressure (Bi-PAP) equipment. The new criteria include a requirement of documentation of the CPAP/Bi-PAP titration study and, after the initial three-month rental period, a face-to-face visit by the treating licensed practitioner with documentation that symptoms of obstructive sleep apnea have improved and objective evidence of adherence to use.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil oxy (25, 27–30)
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4. Clarification of TAR Requirements for Breast Pumps and Breast Pump Supplies

Effective for dates of service on or after December 1, 2018, breast pump supplies (HCPCS codes A4281 – A4286) require documentation on the Treatment Authorization Request (TAR) of medical necessity for each Durable Medical Equipment supply item requested. The TAR must be accompanied by a prescription for a breast pump or breast pump supplies signed and dated by a physician (or the electronic equivalent). Documentation of the name and birth date of the infant being breastfed is no longer required on the TAR or prescription.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura bil dme (25–27)
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5. Updates to the Lists of Contracted Incontinence Products

Effective for dates of service on or after December 1, 2018, products from the following manufacturers are added to the List of Contracted Incontinence Absorbent Products: Attends Healthcare Products, Inc.; Bandz, Inc.; Essity HMS North American, Inc.; McKesson Medical-Surgical; Medline Industries, Inc.; Secure Personal Care; and Sigma Supply & Distribution, Inc.

Effective for dates of service on or after March 1, 2019, certain products from the following manufacturers are deleted from the List of Contracted Incontinence Absorbent Products and are no longer reimbursable: Attends Healthcare Products, Inc.; Essity HMS North American, Inc.; Secure Personal Care; and Smart Choice Medical.

Effective for dates of service on or after March 1, 2019, the List of Contracted Incontinence Creams and Washes is updated. Products from manufacturer Smart Choice Medical are deleted from the list and are no longer reimbursable.

The maximum acquisition cost (MAC) for products deleted from the lists is no longer guaranteed by the manufacturer.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (10)
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6. Sign Language Interpreter Services Code Conversion Reminder

The sign language interpreter services code conversion will replace HCPCS Level III local codes, commonly referred to as local codes, with HIPAA-compliant HCPCS Level II national codes. This billing requirement for sign language interpreter services is mandated by HIPAA and is effective for claims with dates of service on or after January 1, 2019.

For claims with dates of service on or after January 1, 2019, the sign language interpreter services code conversion will be replacing HCPCS Level III local codes Z0324 and Z0326 with HCPCS Level II national code T1013 (sign language or oral interpretive services, per 15 minutes).

As of January 1, 2019, HCPCS Level III local codes Z0328 and Z0329 used to bill for sign language interpreter services will no longer be reimbursable.

Sign language interpreter services are a benefit to facilitate effective communication with deaf or hearing-impaired Medi-Cal recipients. Recipients are not eligible to receive sign language interpreter services in a health facility that is required by law to provide sign language interpreter services.

Providers are encouraged to watch for sign language interpreter service updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update. Providers may complete the Medi-Cal Subscription Service (MCSS) Form to receive timely notifications related to sign language interpreter services.

For additional information, providers may:

Questions regarding the sign language interpreter services code conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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7. Ostomy Medical Supplies No Longer Contracted

Effective for dates of service on or after January 1, 2019, the ostomy HCPCS billing codes have the following updates:

Providers may refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet for the specific HCPCS billing code policy.

Reminder:

A written prescription (or electronic equivalent) signed and dated by the recipient's physician is required. A recipient's need for the item must be reviewed annually by a physician. The HCPCS billing code on the claim must be appropriate for the medical supply item dispensed.

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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8. MAPC Established for Assist Devices and Peak Flow Meters for Inhalers

Effective for dates of service on or after December 1, 2018, the Department of Health Care Services establishes a maximum allowable product cost (MAPC) for covered assist devices (spacers and aerochambers) and peak flow meters intended for use with metered dose inhalers. The MAPC is the price on file for the products that meet the medical supply descriptions and that are currently available within Medi-Cal’s pharmacy claims processing system. There is no change to claim quantity limits.

Medical Supply Description MAPC
Inhaler, Assist Devices (spacer, bag or reservoir [with or without mask] for use with metered dose inhaler) $31.33
Peak Flow Meters, Non-Electronic $15.76

The Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet is updated to reflect this change. Providers may refer to the Medical Supplies section of the appropriate Part 2 manual for detailed policy information.

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9. Electronic SAR Now Supports Attachments

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can now submit Service Authorization Requests (SARs) in an electronic format (eSAR) with attachments. Attachments must be in format of PDF, JPG or TIF. Attachments must be less than 15 megabytes (MB) in size, with the sum of all attachments being less than 150 MB. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit eSARs, providers must:

Then, select one of the available options to submit:

Registered providers and clearinghouses 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 practical reasons to do so.

Providers interested in learning more about eSAR submissions 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 (12); genetic (4)
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10. 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

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  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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11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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