Medi-Cal Update

General Medicine | June 2011 | Bulletin 444

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1. 2011 CPT-4/HCPCS Annual Update: Implementation September 1, 2011

The 2011 updates to the Current Procedural Terminology – 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are listed below. Only those codes representing current or future Medi-Cal benefits are included in the list of additions. Medi-Cal will implement the code additions, changes and deletions for dates of service on or after September 1, 2011. Please refer to the 2011 CPT-4 and HCPCS Level II code books for complete descriptions of these codes. Specific policy, billing information and manual replacement pages reflecting these changes will be released in a future Medi-Cal Update. 

CPT-4 Code Additions  

Lab
82930, 83861, 85598, 86481, 86902, 87501 – 87503, 87906, 88120, 88121, 88177, 88363, 88749
Medicine
91013, 92132 – 92134, 92227, 92228, 93451 – 93464, 93563 – 93568, 96446
Optometry
92132 – 92134, 92227, 92228
Podiatry
11045 – 11047, 76881, 76882
Radiology
76881 – 76882
Surgery
11045 – 11047, 22551, 22552, 29914 – 29916, 31295 – 31297, 31634, 33620 – 33622, 37220 – 37235, 38900, 43283, 43327, 43328, 43332 – 43338, 43753 – 43757, 49327, 49412, 49418, 53860, 57156, 61781 – 61783, 64568 – 64570, 64611, 65778, 65779

HCPCS Level II Code Additions

Chemotherapy
C9276, J9302, J9307, J9315, J9351
Lab
G0432, G0433, G0435
Physician-Administered Drugs
C9274, C9275, C9279, J0171, J0558, J0561, J0597, J0638, J1290, J1826, J2358, J2426, J3095, J3262, J7196, J7309, S0148
Podiatry
Q4117 – Q4121
Surgical Supplies
Q4117 – Q4121

CPT-4 Code Changes

Anesthesia
00100, 00102 – 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214 – 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528 – 00530, 00532, 00534, 00537, 00539, 00540 – 00542, 00546, 00548, 00550, 00560, 00561, 00563, 00566, 00567, 00580, 00600, 00604, 00620, 00622, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00740, 00750, 00752, 00754, 00756, 00770, 00790, 00794, 00796, 00797, 00800, 00802, 00810, 00820, 00830, 00832, 00834, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920 – 00922, 00924, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01916, 01920, 01922, 01924, 01925, 01926, 01930 – 01933, 01935, 01936, 01951 – 01953, 01958, 01960 – 01963, 01965 – 01967, 01991, 01992
Chemotherapy
96401, 96405, 96409, 96411, 96413, 96413, 96413, 96415, 96420, 96425, 96440, 96450, 96521, 96549
Immunizations
90281, 90283, 90284, 90288, 90291, 90371, 90375, 90376, 90378, 90384 – 90386, 90389, 90393, 90396, 90470, 90472, 90476, 90477, 90581, 90585, 90586, 90632 – 90634, 90636, 90644 – 90650, 90657, 90658, 90660, 90662, 90663, 90665, 90669, 90670, 90675, 90676, 90680, 90690 – 90693, 90698, 90700 – 90708, 90710, 90713, 90716 – 90721, 90725, 90727, 90733 – 90736, 90740, 90743, 90746 – 90748
Lab
80100, 80101, 80103, 80156, 80157, 80164, 80185, 80186, 80299, 81000, 81001, 81003, 81020, 81050, 82016, 82017, 82043 – 82045, 82103 – 82106, 82120, 82127, 82128, 82131, 82135, 82136, 82139, 82339, 82240, 82247, 82248, 82270 – 82272, 82274, 82306, 82355, 82360, 82373 – 82376, 82382 – 82384, 82438, 82465, 82480, 82482, 82485, 82491, 82492, 82530, 82541, 82542, 82553, 82554, 82652, 82656, 82658, 82705, 82710, 82747, 82784, 82787, 82803, 82805, 82810, 82926, 82928, 82947, 82952, 82979, 83003, 83009, 83010, 83013, 83018, 83026, 83030, 83033, 83037, 83070, 83071, 83500, 83516, 83518, 83593, 83630, 83661 – 83664, 83700, 83701, 83704, 83876, 83883, 83898, 89908, 83909, 83913, 83918, 83919, 83921, 83950, 83951, 84061, 84152 – 84157, 84160, 84163, 84165, 84182, 84238, 84375 – 84378, 84431, 84480, 84484, 84512, 84704, 85027, 85032, 85378, 85379, 85380, 85396, 85441, 85445, 85460, 85461, 85597, 85613, 85651, 85652, 85670, 85675, 85730, 85732, 86000, 86060, 86063, 86141, 86156, 86157, 86160, 86162, 86171, 86215, 86226, 86255, 86256, 86294, 86300, 86301, 86304, 86316, 86317, 86318, 86334, 86355, 86357, 86359 – 86361, 86367, 86382, 86431, 86480, 86485, 86486, 86590, 86645, 86692, 86703 – 86705, 86708, 86709, 86778, 86788, 86804, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86880, 86885, 86886, 86891, 86900, 86901, 86903 – 86906, 86910, 86911, 86920 – 86923, 86927, 86940, 86975 – 86978, 87001, 87003, 87045, 87046, 87070, 87075, 87076, 87106, 87107, 87143, 87147, 87150, 87158, 87176, 87181, 87184 – 87188, 87190, 87197, 87205 – 87210, 87230, 87250, 87252 – 87254, 87260, 87265, 87267, 87269, 87270, 87272, 87274 – 87276, 87278 – 87281, 87283, 87285, 87290, 87299, 87300, 87301, 87305, 87320, 87324, 87327 – 87329, 87332, 87335 – 87341, 87350, 87380, 87385, 87390, 87391, 87400, 87420, 87427, 87430, 87449 – 87451, 87470 – 87472, 87475 – 87477, 87480 – 87482, 87485 – 87487, 87490 – 87492, 87495 –87498, 87500, 87510 – 87512, 87515 – 87517, 87520 – 57542, 87550 – 87552, 87555 – 87557, 87560 – 87562, 87580 – 87582, 87590 – 87592, 87620 – 87622, 87640, 87641, 87650 – 87653, 87660, 87797 –87801, 87900 – 87904, 88000, 88005, 88007, 88012, 88014, 88016, 88020, 88025, 88027 – 88029, 88104, 88106, 88107, 88108, 88112, 88141, 88142, 88147, 88148, 88150, 88152 – 88155, 88160 – 88162, 88164 – 88167, 88172 – 88174, 88184, 88185, 88187 – 88189, 88230, 88233, 88235, 88237, 88239, 88245, 88248, 88249, 88261 –88264, 88267, 88269, 88271 – 88275, 88285, 88289, 88300, 88314, 88331 – 88334, 88355 – 88356, 88358, 88367, 88368, 88371, 88380, 88381, 88385 – 88388, 89055, 89060, 89258 – 89261, 89290, 89291, 89321, 89322, 89330, 89342 – 89344, 89346, 89352 – 89354, 89356
Medicine
90804 – 90819, 90821 – 90824, 90826 – 90829, 90901, 90935, 90937, 90945, 90947, 90951 – 90957, 90959 – 90968, 90970, 90989, 90993, 91010, 92002, 92004, 92225, 92226, 92551 – 92553, 92556, 92560, 92561, 92565, 92570, 92577, 92585, 92586, 92590 – 92595, 92607, 92620, 92621, 92960, 92961, 92970, 92971, 92974, 92975, 92977 – 92979, 92997, 92998, 93000, 93005, 93041, 93042, 93224 – 93229, 93268, 93270 – 93272, 93279 – 93284, 93306 – 93308, 93320, 93321, 93530 – 93533, 93609, 93613, 93623, 93631, 93701, 93750, 93890, 93892, 93893, 93922, 93923, 93924, 94002, 94003, 94011 – 94013, 94644, 94645, 94660, 94662, 94680, 94681, 94772, 94774 – 94777, 95024, 95115, 95120, 95125, 95130 – 95132, 95134, 95250, 95251, 95807, 95808, 95810, 95812, 95813, 95816, 95819, 95822, 95824, 95827, 95831 – 95834, 95857, 95860, 95861, 95863, 95864, 95866, 95869, 95870, 95872, 95956, 95961, 95962, 95965 – 95967, 95970 – 95975, 95980, 95992, 96000, 96040, 96110, 96111, 96150 – 96154, 96360, 96361, 96365, 96369 – 96374, 96376, 96567, 96570, 96571, 96913, 96920 – 96922, 97024, 97597, 97598, 97605, 97606, 97802 – 97804, 98960 – 98962, 99051, 99053, 99143, 99170, 99201 – 99205, 99211 – 99215, 99218 – 99220, 99291, 99292, 99304 – 99310, 99341 – 99345, 99347 – 99350, 99354 – 99357, 99363, 99364, 99381 – 99386, 99387, 99391 – 99396, 99401 – 99404, 99408, 99409, 99411, 99412, 99460 – 99462, 99468, 99469, 99471, 99472, 99475, 99476, 99478, 99500 – 99503, 99505 – 99507, 99510, 99511, 99601, 99602, 99605 – 99607
Optometry
92002, 92004, 92225
Physician-Administered Drugs
90283 – 90284
Radiology
70240, 71275, 70336, 70371, 70496, 70498, 72159, 72255, 72265, 72270, 73092, 73225, 73542, 73560, 73562, 73564, 73592, 74022, 74185, 74220, 74230, 74240, 74241, 74245, 74261 – 74263, 74290, 74291, 74355, 74360, 74363, 74420, 74425, 74430, 74440, 74450, 74455, 74474, 74480, 74485, 74740, 74742, 75565, 75573, 75630, 75650, 75658, 75660, 75662, 75665, 75671, 75676, 75680, 75685, 75705, 75710, 75716, 75722, 75724, 75726, 75731, 75733, 75736, 75743, 75746, 75756, 75774, 75801, 75803, 75805, 75807, 75809 – 75810, 75825, 75827, 75831, 75833, 75840, 75842, 75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75894, 75896, 75940, 75954 – 75962, 75964, 75968, 76001, 76010, 76098, 76510 – 76514, 76645, 76800 – 76802, 76805, 76810 – 76817, 76830, 76831, 76856 – 76857, 76870, 76872, 76873, 76885, 76886, 76930, 76937, 76940, 76945, 76948, 76998, 77003, 77032, 77055 – 77059, 77073 – 77080, 77082, 77084, 77301, 77371, 77372, 77418, 77422, 77423, 77427, 77520, 77522, 77523, 77525, 77785, 77786, 78000, 78001, 78007, 78018, 78102 – 78104, 78110, 78111, 78120, 78121, 78190, 78268, 78271, 78272, 78300, 78305, 78306, 78315, 78350, 78351, 78451 – 78454, 78458, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78586, 78587, 78591, 78593, 78594, 78700, 78800 – 78802, 78804 – 78806, 78811 – 78816, 79005, 79101, 79200, 79300, 79440
Surgery
10180, 11010 – 11012, 11042 – 11044, 11056, 11057, 11100, 11101, 11450, 11451, 11462, 11463, 11470, 11471, 11720, 11721, 11732, 11755, 11765, 12054, 15002 – 15005, 15100, 15101, 15130, 15136, 15155, 15175, 15176, 15200, 15300, 15335, 15360, 15400, 15420, 15732, 15734, 15736, 15738, 15757, 15758, 15786 – 15789, 15792, 15793, 15819 ,15845, 16020, 16025, 16030, 16035, 16036, 17003, 17110, 17111, 17250, 17311, 17313 – 17315, 19101, 19105, 19125, 19126, 19290, 19291, 19295, 19303 – 19307, 20005, 20100 – 20103, 20206, 20220, 20225, 20240, 20245, 20526, 20552, 20553, 20600, 20605, 20610, 20660, 20664, 20802, 20805, 20808, 20816, 20822, 20824, 20827, 20838, 20930, 20931, 20950, 20955 – 20957, 20962, 20969, 20970, 20972, 20973, 20982, 21012, 21014, 21016, 21025, 21031, 21032, 21116, 21125, 21127, 21141 – 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21270, 21275, 21552, 21554, 21558, 21931, 21933, 21936, 22010, 22015, 22101, 22102, 22112, 22114, 22206 – 22208, 22216, 22226, 22315, 22523 – 22527, 22534, 22614, 22632, 22818, 22819, 22851, 22901, 23120, 23130, 23395, 23410, 23412, 24071, 24332, 24357, 24358, 25073, 25078, 25394, 25830, 26135, 26140, 26145, 26170, 26235, 26236, 26415, 26553, 26554, 26720, 26725, 26727, 26735, 26740, 26742, 26746, 26750, 26755, 26756, 26765, 26861, 27049, 27065 – 27067, 27070, 27071, 27323 – 27326, 27330, 27337, 27339, 27360, 27364, 27427 – 27429, 27616, 27632, 27634, 27658, 27659, 27664, 27665, 27703, 27870, 28041, 28055, 28060, 28272, 28450, 28455, 28465, 28890, 29505, 29805, 29860 – 29863, 29866 – 29868, 29870, 29893, 29900 – 29902, 30801, 30915, 30920, 30930, 31000, 31002, 31020, 31030, 31032, 31050, 31231, 31233, 31235, 31237 – 31240, 31267, 31276, 31287, 31288, 31290 – 31294, 31320, 31511, 31520, 31561, 31577, 31628, 31629, 31631, 31632, 31636 – 31638, 31641, 31645, 31646, 31656, 31730, 32200, 32201, 32405, 32601 – 32606, 32650 – 32665, 32851, 32853, 32855, 32856, 32998, 33202, 33203, 33218, 33220, 33222, 33244, 33254 – 33258, 33265, 33266, 33401, 33403, 33411, 33415, 33463, 33464, 33471, 33475, 33496, 33506, 33507, 33510 – 33519, 33521 – 33523, 33530, 33533 – 33536, 33548, 33615, 33860, 33863, 33864, 33883, 33884, 33886, 33926, 33935, 34501, 34812, 34820, 34825, 34826, 34833, 34834, 34900, 35002, 35013, 35022, 35082, 35092, 35103, 35112, 35122, 35132, 35142, 35390, 35471, 35526, 35623, 35626, 35700, 35701, 35721, 35901, 35903, 35905, 35907, 36440, 36450, 36460, 36468, 36469, 36475, 36476, 36478, 36481, 36500, 36510, 36515, 36516, 36598, 36620, 36625, 36640, 36660, 36680, 36818, 36819, 36832, 36838, 37195, 37205 – 37208, 37215, 37216, 37765, 37788, 38100, 38101, 38102, 38102, 38120, 38129, 38300, 38305, 38500, 38505, 38510, 38520, 38525, 38530, 38542, 38550, 38555, 38562, 38564, 38570 – 38572, 38589, 38700, 38720, 38724, 39560, 39561, 40804, 40805, 41145, 41150, 41153, 41155, 41520, 41805, 41806, 41820, 42104, 42106, 42107, 42145, 42280, 42281, 42953, 43202, 43220, 43226 – 43228, 43234, 43235, 43237, 43239, 43249, 43279, 43280, 43289, 43330, 43331, 43350 – 43352, 43496, 43605, 43631 – 43635, 43647, 43651 – 43653, 43659, 43775, 43842, 43881, 43886 – 43888, 44126 – 44128, 44132, 44133, 44135, 44136, 44180, 44186 – 44188, 44202, 44203, 44213, 44227, 44238, 44386, 44393, 44500, 44602 – 44604, 44680, 44900, 44901, 44970, 44979, 45190, 45381, 45395, 45397, 45499, 45990, 46250, 46260, 46608, 46610, 46612, 46614, 46900, 46910, 46916, 46917, 46924, 47001, 47010, 47011, 47140 – 47145, 47379, 47480, 47490, 47510, 47579, 47801, 48001, 48100, 48102, 48400, 48556, 49040, 49041, 49060, 49061, 49080, 49180, 49220, 49321, 49322, 49324, 49329, 49402, 49419, 49421, 49422, 49424, 49427, 49492, 49495, 49496, 49500, 49501, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49659, 49904 – 49906, 50020, 50021, 50220, 50225, 50230, 50250, 50320, 50382, 50384, 50542, 50544, 50549, 51703, 51741, 51999, 52001, 52282, 52325, 52327, 52344, 53400, 53405, 53420, 53425, 53500, 54050, 54055, 54056, 54057, 54065, 54111, 54112, 54160, 54411, 54417, 54522, 54690, 54692, 54699, 55300, 55559, 55860, 55866, 55875, 55876, 55970, 55980, 56501, 57022, 57023, 57061, 57065, 57106, 57107, 57110 – 57112, 57155, 57282 – 57285, 57296, 57308, 57423, 57425, 57460, 57461, 57531, 57556, 58291 – 58294, 58353, 58541, 58546, 58553, 58555, 58558 – 58563, 58565, 58570, 58572, 58578, 58660 – 58662, 58670 – 58673, 58679, 58740, 58820, 58822, 58823, 58825, 58953, 58956, 59000, 59001, 59012, 59076, 59898, 60659, 61210, 61570, 61580 – 61583, 61586, 61609 – 61613, 61615, 61616, 61624, 61626, 61640, 61697, 61698, 61700, 61796 – 61799, 61864, 61868, 62267, 62269, 62270, 62318, 63040, 63042 – 63044, 63077, 63078, 63620, 63621, 64400, 64402, 64405, 64408, 64412, 64413, 64415 – 64418, 64420, 64421, 64425, 64430, 64435, 64445 – 64450, 64455, 64479, 64480, 64483, 64484, 64505, 64508, 64510, 64517, 64520, 64530, 64575, 64612 – 64614, 64632, 64708, 64712 – 64714, 64744, 64885, 64886, 64890 – 64893, 64895 – 64898, 65756, 65780 – 65782, 66700, 66720, 66740, 66761, 66820, 66982 – 66984, 67031, 67113, 67346, 67415, 68371, 68505, 69110, 69801, 69802

HCPCS Level II Code Changes

Chemotherapy
J9060
Laboratory and Pathology
G0431
Medical Supplies
A4399, A5112, A6011, A6248, A6260 – A6262, A6530, A6533 – A6541, A6544, A6545, A6549, A7013,
B4034 – B4036
Medicine
G0151 – G0154, G8427, G8428, G8440, G8441, G8447, G8448, G8508, G8509, J0598
Physician-Administered Drugs
J0598
Surgical Supplies
Q0499, Q4101 – Q4108, Q4110 – Q4113, Q4115, Q4116

CPT-4 Code Deletions

Immunizations
90465 – 90468
Laboratory and Pathology
82926, 82928, 86903, 89100, 89105, 89130, 89132, 89135, 89136, 89140, 89141, 89225, 89235
Medicine
11040, 11041, 91000, 91011, 91012, 91052, 91055, 91105, 91123, 93012, 93014, 93230, 93231 – 93233, 93235 – 93237, 93501, 93508, 93510, 93511, 93514, 93524, 93526 – 93529, 93539 – 93545, 93555, 93556, 96445
Ophthalmology
92135
Radiology
75992 – 75996, 76150, 76350, 76880
Surgery
20000, 33861, 35454, 35456, 35473, 35474, 35459, 35470, 35480 – 35485, 35490 – 35495, 39502, 39520, 39530, 39531, 43324, 43326, 43600, 49420, 61795, 64573

HCPCS Level II Code Deletions

Chemotherapy
C9259, C9265, J9062, J9110, J9140, J9290, J9291, J9350, S0146,
Medicine
S3905
Ophthalmology
Q1003
Physician-Administered Drugs
C9255, C9256, C9258, C9264, C9265, J0128, J0170, J0559, J0560, J0570, J0580, J0704, J0970, J1390, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1785, J1825, J2321, J2322, S0161, S0196
Radiology
S2270
Surgery
S2344
Surgical Supplies
Q4109

Modifier Additions

AY, AZ, CS, DA, GU, GX, NB, PT

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2. Policy Update for Docetaxel 1 mg

Retroactively effective for dates of service on and after January 1, 2010, the list of reimbursable diagnoses for treatment with docetaxel (taxotere) (HCPCS codes J9171 and X7638) is expanded to include ICD-9-CM 195.0 (malignant neoplasm of head, face and neck). An Erroneous Payment Correction (EPC) will be automatically processed for denied claims. Providers do not need to rebill.

Effective for dates of service on or after May 1, 2011, the following ICD-9-CM codes are required for reimbursement of HCPCS code J9171 (injection, docetaxel, 1 mg):

ICD-9-CM Code Description
174.0 – 175.9 Breast cancer
150.0 – 151.0
235.5
Esophageal cancer
151.0 – 151.9
235.2
Gastric cancer
140.0 – 141.9
143.0 – 149.9
161.0 – 161.9
173.0
195.0
235.1
235.6
Head and neck cancer
162.0 – 162.9 Non-small cell lung cancer
199.0
199.1
Occult primary
158.8
183.0 – 183.9
Ovarian cancer
185 Prostate cancer
162.0 – 162.9
197.0
197.7
198.3
198.5
198.7
209.30
Small cell lung cancer

 

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug a-d (13–14)

 

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3. New Computed Tomography Codes

Effective retroactively for dates of service on or after January 1, 2011, the Department of Health Care Services is implementing the following new CPT-4 codes for computed tomography (CT):

CPT-4 Code Description
74176 Computed tomography, abdomen and pelvis; without contrast material
71477   with contrast material(s)
74178

  without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

These codes must be used when claiming CT for both the abdomen and pelvis on the same date of service. All other CT policy applies to these codes. The codes are split-billable and require a modifier.

Providers are reminded: Claims denied with abdomen CT codes 74150, 74160 and 74170 or pelvis CT codes 72192, 72193 and 72194 should be resubmitted to include codes 74176, 74177 and/or 74178, as appropriate. When claiming CT abdomen and pelvis codes 74176 – 74178, do not claim codes 72192 – 72194 or 74150 – 74170. Claims resubmitted for these codes, prior to November 1, 2011 will not be reduced for late submission.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (1)
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4. Clarification of Physician Administration Fee

Providers are reminded that the price listed on the Medi-Cal Rates page of the Medi-Cal website for each Physician Administered Drug includes the one-time administration fee of $4.46 for injections. Since the administration fee is paid only once for each drug administered, subsequent units claimed must have the administration fee subtracted from the published rate.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Chronic Dialysis Clinics
Medical Services
Pharmacy
Rehabilitation Clinics
inject an over (1)
Clinics and Hospitals
General Medicine
chemo an over (1)

 

 

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5. CPT-4 Immune Globulin Injection Codes Replaced with National HCPCS Codes

Effective for dates of service on or after July 1, 2011, CPT-4 codes 90281 (immune globulin, human, for intramuscular use) and 90283 (immune globulin, human, for intravenous use) will be replaced with corresponding immune globulin HCPCS codes for reimbursement.

An approved Treatment Authorization Request (TAR) is required for reimbursement. Claims submitted with HCPCS codes J1460, J1560, J1566 or J1599 must include an invoice for manual pricing or the claim will be denied.

Deleted CPT-4 Codes Replacement HCPCS Codes
90281
(intramuscular)
J1460
J1559
J1560
J1562
Gamma globulin, 1 cc
Immune globulin, (Hizentra), 100 mg
Gamma globulin, over 10 cc
Immune globulin, (Vivaglobin), 100 mg
90283
(intravenous)
C9270
J1459
J1561
J1566

J1568
J1569
J1572

J1599
Immune globulin, (Gammaplex), non-lyophilized (e.g. liquid), 500 mg
Immune globulin, (Privigen), non-lyophilized (e.g. liquid), 500 mg
Immune globulin, (Gamunex), non-lyophilized (e.g. liquid), 500 mg
Immune globulin, (Gammaplex), lyophilized (e.g. powder),
not otherwise specified, 500 mg
Immune globulin, (Octagam), non-lyophilized (e.g. liquid), 500 mg
Immune globulin, (Gammagard Liquid), non-lyophilized (e.g. liquid), 500 mg
Immune globulin, (flebogamma/flebogamma DIF),
non-lyophilized (e.g. liquid), 500 mg
Immune globulin, non-lyophilized (e.g. liquid), not otherwise specified, 500 mg

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
immun (1); inject cd list (8–9); inject drug a-l (35–36); non ph (10, 18); tar and non cd9 (1)
Rehabilitation Clinics immun (1); inject cd list (8–9); inject drug a-l (35–36); non ph (10, 18)
Chronic Dialysis Clinics
Pharmacy
immun (1); inject cd list (8–9); inject drug a-l (35–36)
Inpatient Services tar and non cd9 (1)
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6. Update to California Childrens Services/Genetically Handicapped Persons Program

Effective June 1, 2011, Incobotulinum Toxin Type A has been added to the California Children’s Services/Genetically Handicapped Persons Program (CCS/GHPP) list of drugs and nutritional products that are not included in a physician’s Service Code Groupings (SCGs) and require a separate SAR.

The following codes will be added/end-dated to/from the CCS SCGs with an effective date of June 1, 2011, or September 1, 2011:

Added Code(s)
Effective Date Code SCGs
June 1, 2011 HCPCS codes: C9280, G0434, J1460 and J1560 01, 02, 03 and 07
June 1, 2011 HCPCS codes: C9270, J1459, J1559, J1561, J1562, J1566, J1568, J1569, J1572, J1599 and Q2040 51
September 1, 2011 HCPCS codes: C9274 – C9276, G0432, G0433, G0435, J0597, J0638, J0960, J1290, J1826, J2358, J2426, J3095, J3262, J7309, J7335, J9302, J9307, J9315, J9351 and S0148 and CPT-4 codes: 31634, 43753 – 43757, 53860, 74176 – 74178, 82930, 83861, 85598, 86481, 86902, 87501 – 87503, 88120, 88121, 88177, 88363, 88749, 91013, 92132 – 92134, 92227, 92228 and 96446 01, 02, 03 and 07
September 1, 2011 HCPCS codes: C9279, J0558 and J0561 and CPT-4 codes: 11045 – 11047, 76881, 76882, 87906, 97597 and 97598, 01, 02, 03, 07 and 12
September 1, 2011 CPT-4 codes: 49418, 93451 – 93464 and
93563 – 93568
02 and 03
September 1, 2011 CPT-4 codes: 65778 and 65779 10
September 1, 2011 HCPCS codes: Q4100 – Q4114 and
Q4117 – Q4121
12
September 1, 2011 HCPCS code: J7196 and CPT-4 code: 64568 51

End-Dated Code(s)
Effective Date Code SCGs
June 1, 2011 HCPCS code: G0430 and CPT-4 codes: 80100, 80101 and 90281 01, 02, 03 and 07
June 1, 2011 CPT-4 code 90283 51
September 1, 2011 HCPCS codes: C9255, C9259, C9264, J9062, J9350 and CPT-4 codes: 75992 – 75996, 76150, 76350, 76880, 82926, 82928, 89100, 89105, 89130, 89132, 89135, 89136, 89140, 89141, 89225, 89235, 91000, 91011, 91012, 91052, 91055, 91105, 91123, 92135, 93012, 93014, 93230 – 93233, 93235 – 93237 and 96445 01, 02, 03 and 07
September 1, 2011 HCPCS codes: J0559, J0560, J0570 and J0580 and CPT-4 codes: 11040, 11041 and 86903 01, 02, 03, 07 and 12
September 1, 2011 HCPCS codes 43600, 49420, 93501, 93508, 93510, 93511, 93514, 93524, 93526 – 93529, 93539 – 93545, 93555 and 93556 02 and 03
September 1, 2011 HCPCS code 20000 12
September 1, 2011 HCPCS code 64573 51

This list contains codes that are not yet effective. Claims billed with codes not yet effective will be denied.

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 and Medical Supplies
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Medical Transportation
Local Educational Agency
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (7); cal child ser (1–2, 6–17, 23–28); genetic (8)
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7. 2011 Federal Poverty Levels for Presumptive Eligibility Program

Effective April 1, 2011 through March 31, 2012, the Presumptive Eligibility Program is to use the following 2011 Federal Poverty Level (FPL) chart for determining income eligibility. Providers should disregard all previous FPL charts.

200 PERCENT OF POVERTY LEVEL
Number of Persons Monthly Income Annual Income
2 $2,452 $29,420
3 $3,089 $37,060
4 $3,725 $44,700
5 $4,362 $52,320
6 $4,999 $59,980
7 $5,635 $67,620
8 $6,272 $75,260
9 $6,910 $82,900
10 $7,548 $90,540
For each additional member, add $638 $7,640

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (6)
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8. Subsequent Gene Expression Panel for Recurrent Breast Cancer

Once-in-a-lifetime HCPCS code S3854 (gene expression profiling panel for use in the management of breast cancer) is reimbursable more than once-in-a-lifetime for the same recipient if the claim documents that the recipient has a new breast cancer occurrence that fits the following medical-necessity criteria:

Failure to document that all six of the above criteria have been met will result in the claim being denied. HCPCS Level II laboratory code S3854 must be billed with ICD-9-CM diagnosis codes 174.0 – 174.9 (malignant neoplasm of female breast). This code is not split-billable, and must not be billed with modifiers 26, TC, or ZS.

For guidelines refer to “Gene Expression Profiling: HCPCS Code S3854” in the Part 2 provider manual section, Pathology: Billing and Modifiers.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
once (1)
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9. Laboratory Frequency Override for Post-Organ Transplant Patients

Effective for dates of service on or after August 1, 2011, frequency restrictions for laboratory procedure claims will be overridden when either the primary or secondary diagnoses on the claim is one of the following codes:

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10. Termination and Conversion of Lidocaine HCl to National HCPCS code

Effective for dates of service on or after July 1, 2011, Physician Administered Drug (PAD) local codes X6462 (lidocaine HCl-20%, 200 mg), X6464 (lidocaine HCl 10%, 10 mg/ml), and X6494 (lidocaine HCl, 4 %, 40 mg/ml) will be converted to HCPCS code J2001 (lidocaine injection for intravenous infusion, 10 mg). The following 13 local codes for lidocaine hydrochloride (HCl) will also be end-dated effective July 1, 2011:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Chronic Dialysis Clinics
Rehabilitation Clinics
General Medicine
Obstetrics
Pharmacy
inject cd list (10–11)
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11. Provider Orientation and Update Sessions

Family PACT

Medi-Cal providers seeking enrollment in the Family PACT (Planning, Access, Care and Treatment) Program are required to attend a Provider Orientation and Update Session. Dates for upcoming sessions are listed below. Registration opens at 8 a.m., with Session I beginning promptly at 8:30 a.m.

Individual and group providers wishing to enroll must send a physician-owner to the session. Non-profit and government clinics seeking to enroll must send their medical director, physician or nurse practitioner who is responsible for oversight of medical services rendered at the service site where the provider wants to enroll.

Office staff members, such as clinic managers, billing supervisors and client eligibility enrollment supervisors, are encouraged to attend. However, these staff members are not eligible to receive a Certificate of Attendance. Enrolled clinicians and staff are encouraged to attend to remain current with program policies and services.

Session Format
Family PACT has created a new session format, which offers an option for currently enrolled providers and staff to attend only the afternoon update session, along with either the clinical session or the billing and coding session.

Session IOverview of the Family PACT Program:

Start Time 8:30 a.m. to 2 p.m.
Instructions Attendance at this presentation is mandatory for clinician providers wishing to enroll in Family PACT and is recommended for other staff who are new to the program or need a refresher.

Note:  The afternoon sessions will run concurrently from 2 p.m. to 4 p.m.

Session IIClinical Practice Alerts:

Start Time 2 p.m. to 4 p.m.
Instructions Clinicians in attendance who wish to become Family PACT providers must also attend this session. Free continuing education (CE) credit is available for Session II. Providers must bring their medical license number if requesting CE credit; a continuing education request form will be available during onsite registration. Other interested clinical staff are welcome to attend and may request free CE credit for this session.

Session IIITips for Successful Family PACT Administration:

Start Time 2 p.m. to 4 p.m.
Instructions Administrators and billers interested in Family PACT Program administration and billing information may attend.

Please note the upcoming Provider Orientation and Update Sessions below.

Los Angeles
July 7, 2011
8:30 a.m. – 4 p.m.
Radisson LAX
6225 West Century Boulevard
Los Angeles, CA 90045
(310) 670-9000
San Luis Obispo
July 21, 2011
8:30 a.m. – 4 p.m.
Embassy Suites 333
Madonna Road
San Luis Obispo, CA 93405
(805) 549-0800
Oakland
August 16, 2011
8:30 a.m. – 4 p.m.
California Endowment
1111 Broadway, 7th Floor
Oakland, CA 94607
(510) 271-4333
Anaheim
August 23, 2011
8:30 a.m. – 4 p.m.
Embassy Suites
11767 Harbor Boulevard
Garden Grove, CA 92840
(714) 539-3300
Bakersfield
September 29, 2011
8:30 a.m. – 4 p.m.
Marriott
801 Truxtun Avenue
Bakersfield, CA 93301
(661) 323-1900 ext 1001

Sacramento
October 18, 2011
8:30 a.m. – 4 p.m.
Four Points by Sheraton
4900 Duckhorn Drive
Sacramento, CA 95834
(916) 263-9000
Palm Springs
November 17, 2011
8:30 a.m. – 4 p.m.
Hyatt Regency Suites
285 North Palm Canyon Drive Palm Springs, CA 92262
(760) 322-9000
Ventura
December 6, 2011
8:30 a.m. – 4 p.m.
Ventura Beach Marriott
2055 E. Harbor Boulevard
Ventura, CA 93001
(805) 643-6000

For a map and directions to these locations, providers can go to the Family PACT website and click “Directions and Map of Location” for the appropriate session location.

Registration
To register for an orientation and update session, providers should:

Providers with no Internet access may request the registration form by calling 1-877-FAMPACT (1-877-326-7228). Providers must supply the following when registering:

Check-In
Check-in begins at 8 a.m. All orientation sessions start promptly at 8:30 a.m. and end by 4 p.m. At the session, providers must present the following:

Note:  Individuals representing a clinic or physician group should use the clinic or group NPI, not an individual NPI or license number.

Certificate of Attendance
Upon completion of the orientation session, each prospective new Family PACT medical provider will receive a Certificate of Attendance. Providers should include the original copy of the Certificate of Attendance when submitting the Family PACT application and agreement forms (available at the session) to Family PACT Provider Enrollment. Providers arriving late or leaving early will not receive a Certificate of Attendance. Currently enrolled Family PACT providers do not receive a certificate.

Contact Information
For more information about the Family PACT Program, please call 1-877-FAMPACT (1-877-326-7228) or visit the Family PACT website.

The Family PACT Program was established in January 1997 to expand access to comprehensive family planning services for low-income California residents.

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12. Chemotherapeutic Drug Ifosfamide Code Conversion

Effective for dates of service on or after July 1, 2011, chemotherapeutic drug Ifosfamide will convert from HCPCS local code X7584 (ifosfamide, 100 mg) to code J9208 (ifosfamide, 1 gm). The maximum dose for code J9208 is 15 gm; however, a dose in excess of 15 gm is allowed with documentation of body surface area greater than 2 meters 2 or when authorization has been obtained.

Code J9208 is reimbursable to certified nurse midwives, nurse practitioners and physician assistants according to standard Medi-Cal policy.  

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug e-o (6); inject cd list (9); inject drug m-z (1)
Chronic Dialysis
Rehabilitation Clinics
Obstetrics
Pharmacy
inject cd list (9); inject drug m-z (1)
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13. Chemotherapeutic Drug Sipuleucel-T: New Benefit

Effective for dates of service on or after July 1, 2011, HCPCS code Q2043 (sipuleucel-T [Provenge]) is a new Medi-Cal benefit. One dose of sipuleucel-T is 250 ml. An approved Treatment Authorization Request (TAR) documenting the following is required:

The recommended course of therapy is three complete doses, given at approximately two-week intervals. In controlled clinical trials, the median dosing interval between infusions was two weeks (range one to 15 weeks). The maximum dosing interval has not been established.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug p-z (8–9); inject cd list (16)
Chronic Dialysis
Rehabilitation Clinics
Obstetrics
Pharmacy
inject cd list (16)

 

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14. Expansion of Chorionic Gonadotropin Testing Benefits

Effective for dates of service on or after July 1, 2011, ICD-9-CM code 995.29 (unspecified adverse effect of other drug, medicinal, and biological substance) will be added to a list of qualifying diagnosis codes for reimbursement of CPT-4 laboratory procedure codes 84702 (gonadotropin, chorionic, quantitative) and 84703 (gonadotropin, chorionic, qualitative).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Chronic Dialysis Clinics
General Medicine
Obstetrics
path chem (6)

 

 

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15. NCCI/Medi-Cal Claim Processing Discrepancy: Modifier Placement

Some claims submitted for laboratory services were inappropriately paid due to poor positioning of modifiers on the claim. Procedure-required modifiers should be positioned on the claim before NCCI-associated modifiers. For Medi-Cal manual purposes, procedure-required and NCCI-associated modifiers are identified as follows.

Procedure-Required Modifiers
Claims for some Medi-Cal procedures require inclusion of a modifier or the claim will be denied. These are procedure-required modifiers.

NCCI-Associated Modifiers
The Centers for Medicare & Medicaid Services (CMS) has identified a set of national modifiers to facilitate claims processing in cases where there is appropriate reason to override an NCCI edit. These are NCCI-associated modifiers.

Actions Being Taken
Providers need take no action for previously processed claims. Claims will be automatically reprocessed. In addition, special claims handling steps are being initiated to ensure claims process correctly. Also, a new Medi-Cal Part 2 provider manual section, Correct Coding Initiative: National – Claim Preparation has been developed with modifier placement examples, and other manual sections updated, to clarify the importance of modifier order on claims.

Note:

NCCI edits were incorporated into the Medi-Cal claims processing system effective March 28, 2011. Efforts were made to anticipate discrepancies between established Medi-Cal edits and NCCI edits but it was understood some differences would be identified only as claims were processed.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Chiropractic
Medical Transportation
Pharmacy
cms comp (17)
Medical Transportation
cms comp (17); modif app (1)
Audiology and Hearing Aids
Durable Medical Equipment and Medical Supplies
Orthotics and Prosthetics
Therapies
cms comp (17); correct (4); correct cod (1–3); modif app (1)
Psychological Services cms comp (17); correct (4); correct cod (1–3)
Adult Day Health Care Centers
Heroin Detoxification
Multipurpose Senior Services Program
correct (4); correct cod (1–3)
Local Educational Agency
Home Health Agencies/Home and Community-Based Services
modif app (1)
Clinics and Hospitals correct (4); correct cod (1–3); modif app (1); path molec (1)
AIDS Waiver Program
Chronic Dialysis Clinics
Expanded Access to Primary Care Program
Rehabilitation Clinics
Vision Care
correct (4); correct cod (1–3); modif app (1)
General Medicine
Obstetrics
cms comp (17); correct (4); correct cod (1–3); modif app (1); path molec (1)

 

 

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16. Code Conversion for Injectable Heparin Sodium

Effective for dates of service on and after July 1, 2011, the following 10 interim X codes for injectable heparin sodium of varying strengths are terminated. Providers should instead bill this injectable with the national HCPCS codes indicated in the left columns of the following chart.

National HCPCS Code Description Terminated Interim X Codes
J1642 Injection, heparin sodium per 10 units X6282, X6284
J1644 Injection, heparin sodium per 1000 units X6286, X6288, X6296, X6298, X6302, X6304, X6306, X6308
 

The maximum dosage is 6.8 gm. However, a dose in excess of 6.8 gm is allowed with documentation of patient weight more than 136 kg.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (8–9, 11, 14)
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17. Certified Nurse Practitioner Specialists Now Independent Medi-Cal Providers

Effective for dates of service on or after July 1, 2011, all Certified Nurse Practitioner (CNP) specialists will be eligible to enroll and bill as Medi-Cal independent providers. Each CNP must:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
gene coun (5); non ph (5, 12–13)
Rehabilitation Clinics
non ph (5, 12–13)

 

 

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18. eTAR Webinars Available for June and August

Medi-Cal providers now have the opportunity to attend free online seminars taught by eTAR training specialists. Webinars are presented live through the Medi-Cal website. Providers are invited to attend a webinar in the comfort of their office.

Registration
First time webinar attendees must register first here. Once registration is complete, select “Course Catalog” from the menu and select “Calendar View.”

June and August Webinars

June 16, 2011 at 9:30 a.m.: eTAR DME-Mobility Providers
This webinar is designed for eTAR providers who submit DME-Mobility eTARs. All functions of the eTAR application will be discussed.

August 3, 2011 at 9:30 a.m.: eTAR
This webinar will discuss every function of the eTAR application.

August 11, 2011 at 1:30 p.m.: eTAR Transportation
This webinar is designed for eTAR providers who submit Non Emergency Medical Transportation (NEMT) eTARs. All functions of the eTAR application will be discussed.

There will also be Q&A sessions during each of the webinars.

Note:

These webinars address submitted and updating electronic TAR submissions. Paper TARs cannot be updated using the eTAR systems. To learn more about submitting eTARs, check the eTAR Program page for future seminars and webinars.

 

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19. NCCI/Medi-Cal Claims Processing Discrepancy: Modifier 55 and MUEs

Some claims submitted for procedure codes billed with modifier 55 (post-operative management only) were inappropriately denied due to differences between National Correct Coding Initiative (NCCI) edits and established Medi-Cal edits. Providers need take no action. Claims using modifier 55 that were inappropriately denied will be reprocessed.

The discrepancy occurred because Medi-Cal was not aware of the Centers for Medicare & Medicaid Services (CMS) mandate that Medically Unlikely Edits (MUEs) are not to be applied to claims submitted for any procedure code billed with modifier 55.

Note:

NCCI edits were incorporated into the Medi-Cal claims processing system effective March 28, 2011. Efforts were made to anticipate discrepancies between established Medi-Cal edits and NCCI edits but it was understood some differences would be identified only as claims were processed.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Durable Medical Equipment and Medical Supplies Orthotics and Prosthetics
Psychological Services
Therapies
Adult Day Health Care Centers
AIDS Waiver Program
Clinics and Hospitals
Chronic Dialysis Clinics
Expanded Access to Primary Care Program
Heroin Detoxification
Multipurpose Senior Services Program
Rehabilitation Clinics
General Medicine
Obstetrics
Vision Care
correct (4)

 

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20. Code Conversion of Prenatal Vitamins

Effective for dates of service on or after August 1, 2011, HCPCS Level III Local Code Z6210 (prenatal vitamin – mineral supplement, 300 day supply) will convert to HCPCS Level II National Code S0197 (prenatal vitamins, 30 day supply). The rate for the 30-day supply will be $3.00 and the frequency will be restricted to 10 in nine months, from the same provider. Code S0197 must be billed with the following antepartum ICD-9-CM diagnosis codes: V22.0 – V23.9 and 640.0 – 676.9.

Claims billing for code Z6210 on or after August 1, 2011, will be denied.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg com lis (2)
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21. Percutaneous Laminotomy/Laminectomy: New Benefit

Effective for dates of service on or after July 1, 2011, HCPCS code C9729 (percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements, [with ligamentous resection, discectomy, facetectomy and/or foraminotomy, when performed] any method under indirect image guidance, with the use of an endoscope when performed, single or multiple levels, unilateral or bilateral; lumbar) is a new benefit. The service must be billed “By Report,” requires an invoice and is only payable to the primary surgeon.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
surg nerv (1)
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22. Increased Reimbursement Rate for Bortezomib Chemotherapy Injection

Retroactively effective for dates of service on or after October 1, 2010, the rate of reimbursement for HCPCS code J9041 (injection, bortezomib) is adjusted up from $40.93 to $44.24 per unit (0.1 mg) to reflect the increase in the average wholesale price (AWP).

Reimbursement for dosages exceeding 35 units requires documentation of body surface area greater than 2.7 meters2, or an approved Treatment Authorization Request (TAR).

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug a-d (6)
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23. Code Conversions for Interim Codes

Effective for dates of service on and after July 1, 2011, interim code X5656 (chloroquine HCl, 50 mg/ml) is no longer a Medi-Cal benefit. Additionally, the following nine interim X codes are converted to national HCPCS codes as indicated:

HCPCS Code Description Terminated Interim X Codes
J0210 Methyldopate HCl, up to 250 mg X5540
J0278 Amikacin sulfate, 100 mg X5558, X5560, X5562
J0300 Amobarbital, up to 125 mg X5566
J0330 Succinylcholine chloride, up to 20 mg X5636, X6828, X6830
J0360 Hydralazine HCl, up to 20 mg X5648

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (2, 4, 9, 12, 16–17)

 

 

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24. Proton-Pump Inhibitor-Induced Hypomagnesemia

Drug Use Review: Educational Information

Background

On March 2, 2011, the U.S. Food and Drug Administration (FDA) informed the public of the risk of hypomagnesemia associated with prolong use of proton-pump inhibitors (PPIs),1 drugs used to reduce gastric-acid. PPIs were the third-largest selling drug class in 2009, with U.S. sales totaling $13.6 billion,2 and approximately 21 million patients filling a prescription for these agents in retail pharmacies.1 In 2008, there were 113 million prescriptions for PPIs.3

Magnesium is an essential element that plays a fundamental role in many cellular and systemic functions:4

  • Energy transfer, storage, and use
  • Protein, carbohydrate, and fat metabolism
  • Maintenance of normal cell membrane function
  • Regulation of parathyroid hormone secretion
  • Lowering of blood pressure
  • Alter peripheral vascular resistance

Hypomagnesemia can lead to serious adverse events that include tetany, arrhythmias, and seizures. Susceptibility to adverse events is increased in patients on concomitant therapy with digoxin or diuretics.1

The high frequency and prolonged use of these drugs, combined with the potential serious complications of magnesium deficiency, makes this an extremely important issue that currently lacks widespread awareness. The goals of this article are the following:

Mechanism

The mechanism responsible for PPI-induced hypomagnesemia is currently unknown; however, long term use of PPIs may be associated with changes in intestinal absorption of magnesium. In most cases reviewed, the hypomagnesemia occurred after one year of PPI treatment, but cases have been reported in patients taking PPIs for as little as three months.1

Clinical Manifestations of Hypomagnesemia

Disruption of magnesium homeostasis can result in disturbances in nearly every organ system, with the cardiovascular system, and central and peripheral nervous systems the most commonly affected.4 Patients with mild hypomagnesemia can be asymptomatic.5 In addition, symptoms such as muscle cramps, palpitations, tremor, and dizziness are common complaints that are not specific to hypomagnesemia.6 Thus, cases of hypomagnesemia may go undiagnosed or unrecognized. Table 1 lists the neuromuscular, cardiovascular, and metabolic effects of hypomagnesemia.

Table 1: Clinical Manifestations of Hypomagnesemia4
Cardiovascular
  • Electrocardiographic abnormalities:
    • Non-specific T-wave changes – U waves
    • Prolong QT and QU interval
    • Repolarization alternans
  • Arrhythmias
    • Premature ventricular contractions – Monomorphic ventricular tachycardia
    • Torsade de pointes
    • Ventricular fibrillation
    • Enhanced digitalis toxicity
Neuromuscular
  • Muscular weakness
  • Seizure
  • Tetany
  • Vertical and horizontal nystagmus
  • Tremors
  • Paresthesias
  • Positive chvostek sign and trousseau sign
Metabolic
  • Hypokalemia (occurs in 40-60% of cases)
  • Hypocalcemia (sign of severe hypomagnesemia)

Monitoring

Serum magnesium is not routinely included in standard clinical tests and would need to be specifically ordered. The FDA recommends obtaining baseline serum magnesium prior to initiation of prescription PPIs and periodic monitoring in:1

Magnesium deficiency sensitizes the myocardium to digoxin, which may result in digoxin toxicity, and subsequent increased susceptibility to digoxin-related arrhythmias. Loop diuretics (e.g. furosemide) and thiazide diuretics (e.g. hydrochlorothiazide) cause large increases of magnesium excretion by inhibiting magnesium reabsorption.4 Other drugs that also cause hypomagnesemia include aminoglycoside antibiotics, cisplatin, and amphotericin B.1 Other causes of magnesium deficiency include starvation, alcoholism, total parenteral nutrition, gastrointestinal losses (e.g. diarrhea, vomiting, fistulas), and renal losses (e.g. inherited tubular disorders, metabolic acidosis).4

Treatment

Oral magnesium supplements are generally recommended for treatment of hypomagnesemia. Patients with severe or symptomatic hypogmagnesemia should be treated with intravenous magnesium.6 Some cases of hypomagnesemia require the discontinuation of the PPI, in addition to magnesium supplementation.1 Such patients may require substitution with a histamine-2 blocker.6 For patients on diuretic therapy, consider replacement with potassium-sparing diuretics, such as amiloride, which can increase magnesium.5

Data Analysis

A retrospective analysis was conducted for the period of March 1, 2010 through February 28, 2011 to determine the extent of magnesium monitoring, the incidence of hypomagnesemia in FFS recipients on long-term therapy with PPIs, and the number of recipients on digoxin and/or diuretic (thiazide and/or loop diuretics) therapy during this period. Table 2 lists the inclusion and exclusion criteria for this analysis:

Table 2: Inclusion and Exclusion Criteria
Inclusion Criteria Exclusion Criteria
  • FFS Recipient
  • Continuously Eligible
  • Long-Term PPI Therapy (>90 Days Supply of PPI)
  • Medi-Cal Managed Care Recipients
  • Medicare Eligible Recipients

 

Table 3: Magnesium Monitoring and Diagnosis for Hypomagnesemia
Number of Recipients with >90 Days Supply of PPIs: 74,188
Laboratory Monitoring - Magnesium (CPT Code 83735)
Yes - 11,514 (15.5%) No - 62,674 (84.5%)
Diagnosis for Hypomagnesemia (ICD-9-CM – 275.2) Diagnosis for Hypomagnesemia (ICD-9-CM – 275.2)
Yes - 212 (1.8%) No - 11,302 (98.2%) Yes - 33 (0.1%) No - 62,641 (99.9%)

† Diagnosis had to occur after first captured PPI claim

Table 4: Recipients on Digoxin and/or Diuretic Therapy
Drug (s) Number of Recipients (%)
Digoxin Only 527 (0.7%)
Diuretic(s) Only 22,460 (30.3%)
Digoxin and Diuretic(s) 891 (1.2%)

The results of the analysis (Table 3) showed 74,188 recipients had more than 90 days supply of PPIs during the study period; 15.5 percent (11,514) of which had a laboratory claim for serum magnesium level, whereas the remaining 84.5 percent (62,674) did not. Of the recipients that had a laboratory claim for magnesium, 1.8 percent (212) had a diagnosis for hypomagnesemia compared to 0.1 percent (33) for the group of recipients that did not have a laboratory claim for magnesium. While 30 percent of PPI recipients were also on diuretic drug therapy during the study period, less than 2 percent were on digoxin therapy (Table 4).

Discussion

Consistent with national trends, PPIs are one of the most widely used drug classes in the FFS recipient population, ranking 2nd highest for total dollars paid. PPIs are extremely effective gastric acid suppressants and have advanced the treatment of a variety of acid-peptic diseases (e.g. gastroesophageal reflux disease (GERD), peptic ulcers).7 Although many patients benefit from PPI use, many use PPIs longer than necessary or inappropriately.6 Safety concerns related to adverse effects of PPIs have called for more judicious use of PPIs. Adverse effects associated with the use of PPIs include pneumonia, Clostridium difficile infection, fractures, antiplatelet interaction, and now hypomagnesemia.6

Recommendations

References

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25. Drug Screen Billing Codes Not Reimbursable with TAR/SAR

Effective for dates of service on or after July 1, 2011, CPT-4 drug testing codes 80100, 80101 and 80104 are not reimbursable despite submission of a Treatment Authorization Request/Service Authorization Request (TAR/SAR). Additionally, HCPCS code G0430 will be placed on terminated status for Medi-Cal.

As of June 1, 2011, the above codes were placed on non-pay status, however the CPT-4 codes were potentially reimbursable with an approved TAR or SAR. HCPCS code G0430 was terminated by the Centers for Medicare & Medicaid Services (CMS) effective December 31, 2010, and is therefore no longer valid for Medi-Cal.

When billing for drug screening, providers must use HCPCS codes G0431 (drug screen, qualitative; multiple drug classes by high complexity method, per patient encounter) and G0434 (drug screen, qualitative; multiple drug classes other than chromatographic method, each patient encounter).

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26. 2011 Federal Poverty Levels for CDP: EWC

Effective April 1, 2011 through March 31, 2012, the Cancer Detection Programs: Every Woman Counts (CDP: EWC) program is to use the following 2011 Federal Poverty Level (FPL) chart for determining income eligibility. Providers should disregard all previous FPL charts.

200% OF POVERTY LEVEL
Number of Persons Monthly Income Annual Income
1 $1,815 $21,780
2 $2,452 $29,420
3 $3,089 $37,060
4 $3,725 $44,700
5 $4,362 $52,340
6 $4,999 $59,980
7 $5,635 $67,620
8 $6,272 $75,260
For each additional member, add $637 $7,640

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

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Clinics and Hospitals
can detect (8)
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27. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Addition, effective April 1, 2011  
NDC Labeler Code Contracting Company’s Name
51167 VERTEX PHARMACEUTICALS, INC.

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

Provider Manual(s) Page(s) Updated
Pharmacy drugs cdl p5 (10)
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28. New Guidelines for Authorization of Ranibizumab

Based on the results of the recent National Eye Institute (NEI) study “Comparison of AMD Treatments Trials (CATT)”, the Department of Health Care Services (DHCS) has developed additional guidelines for the authorization of ranibizumab (Lucentis™, Genentech) for the treatment of exudative senile macular degeneration. The CATT Study compared the efficacy of intravitreal injections of ranibizumab and bevacizumab (Avastin™, Genentech) and concluded that at one (1) year, bevacizumab and ranibizumab had equivalent effects on visual acuity when administered according to the same schedule. In addition, ranibizumab given as needed with monthly evaluation had effects on vision that were equivalent to those of ranibizumab administered monthly.

Given the results of the CATT Study and California Code of Regulations (CCR), Title 22, Section 51003 (f), which states “Authorization may be granted only for the lowest cost item or service covered by the Medi-Cal program that meets the beneficiary's medical needs,” DHCS expects providers to use bevacizumab rather than ranibizumab in the treatment of exudative senile macular degeneration since the cost of bevacizumab is significantly lower than ranibizumab. DHCS also recognizes that there may be instances or special circumstances when it may be prudent to use ranibizumab rather than bevacizumab. When this occurs, DHCS requires providers to include the following on the Treatment Authorization Requests (TARs) for ranibizumab (HCPCS code J2778: Ranibizumab Injection, 0.1 mg) when prescribed for the treatment of exudative senile macular degeneration:

All other policy for ranibizumab remains unchanged.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
ophthal (5)
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29. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

inject drug a-l (20)
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