Medi-Cal Update

Durable Medical Equipment and Medical Supplies | January 2019 | Bulletin 520

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1. 2019 HCPCS Annual Update: Policy Updates

The 2019 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2019 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 February 1, 2019. Providers should refer to the 2019 HCPCS Level II code book for complete descriptions of these codes.

Providers should refer to the HCPCS Annual Update page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Therapies
Vision Care
medi non hcp (2)
Audiology and Hearing Aids hear aid bill (3, 4); hear aid cd (1, 3); medi non hcp (2); tax (10)
Chronic Dialysis Clinics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12)
Clinics and Hospitals
General Medicine
chemo an over (2); chemo drug a-d (3, 8, 23, 24, 31); chemo drug e-o (7, 8, 18, 21); chemo drug p-z (9–12, 19, 20); inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); medne tele (5); modif used (12); non ph (12–14, 25–27); once (1); ophthal (16); radi dia ult (3); radi onc (7–9); surg eye (14); surg integ (5); surg nerv (3)
Durable Medical Equipment
Orthotics and Prosthetics
medi non hcp (2); tax (10)
Obstetrics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12); non ph (12–14, 25–27); once (1); radi dia ult (3); radi onc (7–9)
Pharmacy inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); tax (10)
Rehabilitation Clinics inject cd list (2–11, 13–16); inject drug a-d (14, 15, 37); inject drug e-h (2–5, 8, 23, 24, 30, 31); inject drug i-m (1, 2, 15–17); inject drug n-r (9–12, 17); inject drug s-z (14, 15, 20, 21); medi non hcp (2); modif used (12); non ph (12–14, 25–27)
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2. EPSDT PDHC and PDN: TAR Submission Update

Effective immediately, providers rendering Pediatric Day Health Care (PDHC) or Private Duty Nursing (PDN) services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit must indicate so on their Treatment Authorization Requests (TARs).

For electronic TARs (eTARs), providers must select the appropriate special handling code on the Patient Information page:

For paper 50-1 TARs, providers must include “EPSDT PDHC” or “EPSDT PDN” in the Specific Services Requested field (Box 10A).

For additional TAR information, contact: PDNinquiries@dhcs.ca.gov.

Any email containing protected health information (PHI) or personal information (PI) should be sent via secure or encrypted email.

Note:

California Children’s Services’ (CCS) Service Authorization Requests (SARs) are not affected by this update.

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
Inpatient Services
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Therapies
Pharmacy
tar comp (8); tar field (2); cal child (3)
Adult Day Health Care Centers
Heroin Detoxification
Hospice Care Program
tar comp (8); tar field (2)
Long Term Care tar field (2)
Home Health Agencies/Home and Community-Based Services ped (3); tar comp (8); tar field (2); cal child (3)
Local Educational Agency
Vision Care
cal child (3)
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3. National Correct Coding Initiative Quarterly Update for January 2019

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) 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 January 1, 2019.

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

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4. Updates to the List of Contracted Sterile Needles

Effective for dates of service on or after January 1, 2019, six products by Arkray USA, Inc and one product by Becton, Dickinson and Company (BD) are added to the List of Contracted Sterile Needles (HCPCS A4215) and are eligible for reimbursement.

Effective for dates of service on or after March 1, 2019, manufacturer item numbers 320119 and 320109 by BD are updated with a new maximum allowable product cost (MAPC).

The Universal Product Number (UPN) on the claim billed must be the exact UPN on the dispensed product's package. Listing of contracted products does not guarantee the product's availability.

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5. Enteral Nutrition Product-Specific Criteria Modified for Compleat Products

Effective for dates of service on or after October 22, 2018, the product-specific criteria restricting all Compleat products by Nestlé HealthCare Nutrition in the standard category are modified. To be considered for authorization of Compleat products, the beneficiary must meet the medical criteria for standard products and all of the following product-specific criteria:

The List of Enteral Nutrition Products is updated to reflect this change.

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 beneficiary and claimed for reimbursement by the provider.

Medi-Cal beneficiaries 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 (855) 795-0634, or by sending a written request to the following address:

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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6. Updates to the List of Contracted Wound Care Advanced Dressings

Effective for dates of service on or after February 1, 2019, certain products from manufacturers Ferris Mfg. Corp., Hartmann USA, Inc. and Hydrofera, LLC are added to the List of Contracted Wound Care Advanced Dressings.

Effective for dates of service on or after April 1, 2019, certain products from manufacturers Hartmann USA, Inc. and Hollister are deleted from the List of Contracted Wound Care Advanced Dressings 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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7. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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For more information about MCSS, please visit the MCSS Help page.

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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