Medi-Cal Update

Durable Medical Equipment and Medical Supplies | November 2019 | Bulletin 530

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1. DME and Medical Supplies for Recipients Impacted by the State of Emergency

Update: Replacement Durable Medical Equipment (DME) and Medical Supplies for Recipients Impacted by Fires and Extreme Weather Conditions or Public Safety Power Shutoff

On October 28, 2019, in response to the Governor’s recent proclamation of a statewide state of emergency due to the risk of wildfires, the Department of Health Care Services (DHCS) issued guidance for dispensing replacement medication(s) to recipients impacted by fires and extreme fire weather conditions or public safety power shutoff. This article provides additional guidance for dispensing DME and medical supplies.

Providers are instructed to incorporate the statement “Patient impacted by fires and extreme fire weather conditions or public safety power shutoff.” within the Miscellaneous Information field on the Treatment Authorization Requests (TAR) for DME, medical supplies or situations requiring a TAR.

DME and medical supply providers must provide requested equipment or supplies immediately or, for items not in stock, as soon as possible, if the need to dispense DME or medical supplies is related to the recipient’s displacement or subjection to fires and extreme fire weather conditions or public safety power shutoff. Providers must not have the recipient return after receiving TAR approval. The need for a TAR should not negatively affect the decision to provide DME or medical supplies immediately or as soon as possible, and the TAR can be submitted retroactively. It is imperative that the impacted recipient receive the DME or medical supply in a timely manner to facilitate compliance and assist the recipient to perform activities of daily living.

TARs for new or replacement DME or medical supplies will be automatically approved if the TAR indicates that the recipient is impacted by fire or by power shutoffs, and the provider will be paid for the claim for the DME or medical supply. The negative impact of the fire or power shutoff, alone, will meet the criteria of medical necessity.

Providers are encouraged to monitor the Medi-Cal website for future updates. Questions regarding this notice may be directed to the Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, except holidays.

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2. Policy for Medical Supply Billing Codes Updated to DME Supply Billing Codes

Effective for dates of service on or after February 1, 2020, the following medical supply billing codes are updated to Durable Medical Equipment (DME) supply billing codes: HCPCS codes A4222, A4230 – A4232, A4483, A7002 – A7004, A7006 – A7008, A7010, A7012, A7013, A7016, B4035 and S8186. Note that codes A4230 – A4232 and A7008 are not benefits.

These HCPCS codes that describe items used in the operation of DME will no longer be medical supply codes on the List of Medical Supplies Billing Codes, Units and Quantity Limits. These HCPCS codes must be billed as DME supply codes.

Updates to Medical Supply Codes
Effective for dates of service on or after February 1, 2020, medical supply HCPCS codes are updated as follows:

A4223

Infusion supplies not used with external infusion pump, per cassette or bag. Use to bill all necessary supplies that are not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to administrative sets and syringes, tubing, extension tubing, connecting devices and port caps) for the administration, without a pump, of non-insulin drugs.

Bill one (1) quantity unit per each administrative/infusion set/kit or per each separate item (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 30 units per 27-day period require authorization.

Documentation of product cost (an invoice, manufacturer’s catalog page or price list) is required as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Refer to DME supply HCPCS code A4222 for infusion supplies used with an external infusion pump.

B4034 Enteral feeding supplies; syringe fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by syringe and maintain the feeding site.
B4036

Enteral feeding supplies; gravity fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by gravity and maintain the feeding site.

For claims using HCPCS code B4034 and B4036, bill one (1) quantity unit per each administrative/supply set/kit or per each separate item, (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 31 units per 27-day period require authorization.

HCPCS code B4034 and B4036 require documentation of product cost (an invoice, manufacturer’s catalog page or price list) as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Note:

HCPCS code B4035, enteral feeding supplies (pump fed), is updated to a DME supply code.

Effective for dates of service on or after February 1, 2020, HCPCS codes B9998, B9999 and S1015 will be end-dated. Providers must bill the items using the following codes:

Updates to DME Supply Codes
HCPCS codes A4230 – A4232 and A7008 are no longer benefits. The table below specifies policy for new DME supply codes A4483, A7002 – A7004, A7006, A7007, A7010, A7012, A7013, A7016, B4035 and S8186. In addition, policy for codes A4222, A4224, A4225 and E0574 is as follows.


HCPCS Code
Description Taxable/Non-Taxable Frequency Limit, Any Provider
A4222 * + Infusion supplies for external drug infusion pump, per cassette or bag Non-taxable --
A4224 * + ^ Supplies for maintenance of insulin infusion catheter, per week Non-taxable 1 per week
A4225 * + ^ Supplies for external insulin infusion pump, syringe type cartridge, sterile, each Non-taxable 15 per month
A4483 * + ^ Moisture exchanger, disposable, for use with invasive mechanical ventilation Non-taxable (no change) 31 per month
A7002 * + Tubing, used with suction pump, each Non-taxable 4 per month
A7003 * + Administration set, with small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7004 * + Small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7006 * + Administration set, with small volume filtered pneumatic nebulizer Taxable (no change) 1 per month
A7007 * + Large volume nebulizer, disposable, unfilled, used with aerosol compressor Taxable (no change) 1 in 2 months
A7010 * + Corrugated tubing, disposable, used with large volume nebulizer, 100 ft Taxable (no change) 1 in 2 months
A7012 * + Water collection device, used with large volume nebulizer Taxable (no change) 2 per month
A7013 * + Filter, disposable, used with aerosol compressor or ultrasonic generator Taxable (no change) 2 per month
A7016 * + Dome and mouthpiece, used with small volume ultrasonic nebulizer Taxable (no change) 2 per year
B4035 * + ^ Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape Taxable 31 per month
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer Taxable (no change) 1 in 5 years
S8186 * + Swivel adaptor Non-taxable (no change) 2 in 12 months

*  This code must be billed with modifier NU. Modifiers RB and RR are not allowed.
+  This code is for patient-owned equipment.
^  This code must be billed using the “from-through” (block-billing) method when billing for more than one day of service.

HCPCS code A7016 may be reimbursed only when used with code E0574. Authorization for rental of code E0574 may be granted in increments of up to three months, both for the initial authorization and for reauthorization. Authorization for purchase of code E0574 may be granted for one device every five years. Claims for code E0574 must include modifier NU, RR or RB.

HCPCS code S8186 is not covered by Medicare and should be billed to Medi-Cal directly.

HCPCS codes A4224 and A4225 are reimbursable under the Presumptive Eligibility for Pregnant Women (PE4PW) program.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (1)
Audiology and Hearing Aids medi non hcp (1); tax (6–8, 10, 12, 13)
Durable Medical Equipment dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); tax (6–8, 10, 12, 13)
General Medicine
Obstetrics
Clinics and Hospitals
medi non hcp (1); presum bill (12)
Orthotics and Prosthetics dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1); tax (6–8, 10, 12, 13)
Pharmacy dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); presum bill (12); tax (6–8, 10, 12, 13)
Therapies dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1)
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3. Updates to the List of Contracted Intermittent Urinary Catheters

Effective for dates of service on or after January 1, 2020, certain products from the following manufacturers are added to the List of Contracted Intermittent Urinary Catheters:

Effective for dates of service on or after March 1, 2020, certain products from the following manufacturers are deleted from the list and are no longer reimbursable:

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

Additionally, certain manufacturer names, item numbers and descriptions are updated.

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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4. Frequency Limit Updated for Certain DME Codes

Effective for dates of service on or after December 1, 2019, the following Durable Medical Equipment (DME) codes have a frequency limit of one in five years:

HCPCS
Code
Description
E0480 Percussor, electric or pneumatic, home model
E0481 Intrapulmonary percussive ventilation system and related accessories
E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
E0561 Humidifier, non-heated, used with positive airway pressure device
E0562 Humidifier, heated, used with positive airway pressure device
E0570 Nebulizer, with compressor
E0600 Respiratory suction pump, home model, portable or stationary, electric
E0618 Apnea monitor, without recording feature
E0619 Apnea monitor, with recording feature
E1353 Regulator
E1355 Stand/rack

In addition, the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section of the Part 2 manual incorrectly listed HCPCS code E1353 (regulator) as a rental item. This code is reimbursable for purchase only. This item may be reimbursed by Medi-Cal when a patient meets criteria for supplemental oxygen, owns an oxygen delivery system, or an oxygen concentrator and requires replacement of the regulator.

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

Provider Manual(s) Page(s) Updated
Orthotics and Prosthetics
Therapies
dura cd (14); dura cd fre (2)
Durable Medical Equipment
Pharmacy
dura oxy (12, 14–15, 29, 48–50); dura cd (14); dura cd fre (2)
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5. Wound Care Advanced Dressings No Longer Contracted

Effective for dates of service on or after April 1, 2020, the wound care advanced dressings 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.

Reminders:   

A signed and dated prescription written by a physician is required, ordering only those medical supplies necessary for the care of the recipient and as documented in the recipient’s medical record. The number of wounds being treated must also be documented. The prescription must be dated within 12 months of the date of service on the claim. The HCPCS billing code on the claim must be appropriate for the medical supply 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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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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