Medi-Cal Update

General Medicine | September 2015 | Bulletin 495

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1. Provider Manual Section Updates for ICD-10

Effective October 1, 2015, Medi-Cal provider manual sections are updated with the International Classification of Diseases, 10th Revision (ICD-10) codes and policy. Medi-Cal provider manual sections are updated to comply with the Health Insurance Portability and Accountability Act (HIPAA) ICD-10 transition.

Updates to the provider manual sections include:

Providers will no longer be able to refer to the Medi-Cal provider manuals for ICD-9-CM diagnosis and ICD-9-CM Volume 3 codes on or after September 16, 2015. Providers can still view ICD-9 policy in the ICD-9 Policy Holding Library on the ICD-10 page of the Medi-Cal website. Refer to the ICD-9 Policy Holding Library for ICD-9 policy for dates of service/dates of discharge effective through September 30, 2015.

For general ICD-10 information, click on the ICD-10 FAQs.

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

Provider Manual(s) Section(s) Updated
Acupuncture acu exc; appeal form; cif sp; cms comp
Adult Day Health Care Centers appeal form; audio exu; cif sp op; community ex; community ipc; correct cod; occu exu; phys exu; rural ex; speech exu; tar comp; tar dis; ub comp op
AIDS Waiver Program aids; aids bil ex; appeal form; cif sp op; correct cod; medi cr op ex; medi non hcp; ub comp op
Audiology and Hearing Aids appeal form; audio exc; cal child bil cms; cif sp; cms comp; correct cod; genetic; hear aid ex; medi cr cms exa; medi non hcp; speech exc; tar comp
Chiropractic appeal form; chiro; chiro exc; cif sp; cms comp; medi cr cms exa; medi cr ub ex
Chronic Dialysis Clinics appeal form; blood; blood ub; cal child bil ub; cif sp op; correct cod; dial chr; dial ex ub; genetic; immun; inject an over; inject bil ub; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; medi cr op ex; medi non cpt; medi non hcp; non inject; path bil; path bil ub; path chem; path cyto; supp drug bil; tar comp; tar dis; ub comp op
Clinics and Hospitals abort; anest; anest ub; appeal form; blood; blood ub; cal child bil ub; cardio; cardio bil ub; chemo an over; chemo drug a-d; chemo drug e-o; chemo drug p-z; cif sp op; correct cod; dial chr; dial ex ub; ev woman; ev woman ex ub; eval; fam planning; fam planning ub; gene coun; genetic; hyst; immun; incont; inject an over; inject bil ub; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; medi cr op ex; medi non cpt; medi non hcp; medne; medne neu; medne non; minor; non inject; non ph ub; ophthal; ophthal cd; path bil; path bil ub; path chem; path cyto; path drug; path immun; path micro; path molec; path surg; podi; podi ub; preg com exu; preg determ; preg early; preg ex ub; preg fetal; prescript; psych; radi; radi bil ub; radi dia; radi dia ult; radi nuc; radi onc; rural ex; spec; ster; supp drug bil; surg; surg bill ub; surg cardio; surg eye; surg integ; surg nerv; surg urin; tar comp; transplant; tuber; ub comp op
Durable Medical Equipment appeal form; cal child bil cms; cif sp; cms comp; correct cod; dura bil dme; dura ex; enteral; genetic; incont; incont ex; incont prod belt; incont prod brief; incont prod protect; incont prod shield; incont prod und; mc sup ex; medi cr cms exa; medi cr ub ex; medi non hcp; tar comp; tar dis
DUR Manual 20; 30
Expanded Access to Primary Care Program appeal form; cif sp op; correct cod; ub comp op
General Medicine abort; anest; anest cms; appeal form; blood; blood cms; cal child bil cms; cardio; cardio bil cms; chemo an over; chemo drug a-d; chemo drug e-o; chemo drug p-z; cif sp; cms comp; correct cod; dial ex cms; drugs cdl p8; ev woman; ev woman exc; eval; fam planning; fam planning cms; gene coun; gene ex; genetic; hyst; immun; incont; inject an over; inject bil cms; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; medi cr cms exm; medi non cpt; medi non hcp; medne; medne neu; medne non; minor; non inject; non ph cms; ophthal; ophthal cd; path bil; path bil cms; path blood ex; path chem; path cyto; path drug; path immun; path micro; path molec; path surg; physician ndc cms; podi; podi cms; preg com exc; preg determ; preg early; preg ex cms; preg fetal; prescript; psych; radi; radi bil cms; radi dia; radi dia ult; radi nuc; radi onc; spec; ster; surg; surg bil cms; surg cardio; surg eye; surg integ; surg nerv; surg urin; tar comp; transplant; tuber
Heroin Detoxification appeal form; cif sp op; correct cod; medi cr op ex; medi non hcp; tar comp; ub comp op
Home Health Agencies/Home and Community-Based Services appeal form; cal child bil ub; cif sp op; genetic; home hlth ex; medi cr op ex; medi non hcp; tar comp; tar dis; ub comp op
Hospice Care Program appeal form; cif sp op; hospic bil ex; medi cr op ex; medi non hcp; tar comp; ub comp op
Inpatient Services appeal form; cal child bil ub; cif sp ip; diagnosis ip; genetic; hyst; inp ment; medi cr ip ex; medne; minor; ob rev drg; ob rev instr; ob ub ex drg; rev cd ip; ster; tar comp; tar dis; tar req ext; transplant; transplant ex ip; ub comp ip; ub comp ip ex; ub spec ip; ub tips ip
Local Educational Agency appeal form; cal child bil ub; cif sp op; genetic; loc ed bil; loc ed bil ex; ub comp op
Long Term Care admis; appeal form; cif sp ltc; incont; leave; medi cr ltc ex; pay ltc comp; share ltc; tar comp ltc; tar dis
Medical Transportation appeal form; cal child bil cms; cif sp; cms comp; genetic; mc tran air ex; mc tran gnd ex; medi cr cms exa; medi cr ub ex; medi non hcp; tar comp; tar dis
Multipurpose Senior Services Program appeal form; correct cod; multi sen ex; ub comp op
Obstetrics abort; anest; anest cms; appeal form; cal child bil cms; cif sp; cms comp; correct cod; ev woman; ev woman exc; eval; fam planning; fam planning cms; gene coun; gene ex; genetic; hyst; immun; inject an over; inject bil cms; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; medi cr cms exm; medi non cpt; medi non hcp; minor; non inject; non ph cms; path bil; path bil cms; path blood ex; path chem; path cyto; path drug; path immun; path micro; path molec; path surg; physician ndc cms; preg com exc; preg determ; preg early; preg ex cms; preg fetal; radi; radi bil cms; radi dia; radi dia ult; radi nuc; radi onc; ster; surg; surg bil cms; surg urin; tar comp; tuber
Orthotics and Prosthetics appeal form; cal child bil cms; cif sp; cms comp; correct cod; genetic; medi cr cms exa; medi cr ub ex; medi non hcp; ortho; ortho ex; ortho1 form; tar comp
Part 1 obra
Pharmacy appeal form; blood; cal child bil cms; cal child bil ph; cif sp; cms comp; compound comp; compound ex; drugs cdl p8; dura bil dme; dura ex; enteral; genetic; immun; incont; incont ex; incont prod belt; incont prod brief; incont prod protect; incont prod shield; incont prod und; inject an over; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; mc sup ex; medi cr ph ex; medi non hcp; ortho; ortho1 form; ortho ex; pcf30-1 comp; pcf30-1 ex; tar comp; tar sub drug
Psychological Services appeal form; cal child bil cms; cif sp; cms comp; correct cod; genetic; medi cr cms exa; medi cr ub ex; medi non hcp; psychol ex; spec; tar comp
Rehabilitation Clinics acu exu; appeal form; audio exu; cal child bil ub; cif sp op; correct cod; genetic; immun; inject an over; inject bil ub; inject drug a-d; inject drug e-h; inject drug i-m; inject drug n-r; inject drug s-z; medi cr op ex; medi non hcp; non inject; non ph ub; occu exu; phys exu; speech exu; supp drug bil; tar comp; ub comp op
Therapies appeal form; audio exc; cal child bil cms; cif sp; cms comp; correct cod; genetic; medi cr cms exa; medi cr ub ex; medi non hcp; occu exc; phys exc; speech exc; tar comp; tar dis
Vision Care appeal form; cal child bil cms vc; cif sp vc; cms comp vc; contact lens; contact lens ex; correct cod; eye app; eyeglass fram; eyeglass fram ex; eyeglass lens; eyeglass lens ex; genetic; low vision; medi cr vc ex; medi non cpt; medi non hcp; minor; pro serv; pro serv cd; pro serv ex; rates max eye app; rates max optom; tar comp vc
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2. CA-MMIS Health Enterprise: PE Provider Registration and Applicant Enrollment

On September 21, 2015, qualified Medi-Cal providers enrolled in the Breast and Cervical Cancer Treatment Program (BCCTP), Child Health and Disability Prevention (CHDP) program and Hospital Presumptive Eligibility (PE) program will begin enrolling applicants through the CA-MMIS Health Enterprise (HE) Portal.

Provider Registration
To begin, providers should designate an employee as their Organization Administrator (Org Admin) who is required to be the first user to register in the HE Portal. The Org Admin will have “super user” privileges and is responsible for creating additional user IDs for other organization staff, maintaining user IDs and privileges and resetting user passwords. The system will automatically assign the Org Admin role to the first registered user for a specific National Provider Identifier (NPI). To register and obtain an HE user ID, the following information is required:

When this information is submitted into the HE Portal, the system will send two separate emails - one that contains the new user ID, and one that contains a first-time use password to log into the HE Portal. When logging into the HE Portal for the first time, the system will prompt users to answer personal challenge questions and create a new password. These personal challenge questions will allow users to reset their passwords through HE’s self-service password reset functionality. All users will receive two separate emails for initial login. The Org Admin may also create additional Org Admin users to serve as a backup and assist with managing user IDs within their organization.

Applicant Enrollment
Once registered in the HE Portal, qualified Medi-Cal providers may access their program’s enrollment application under the “Member” tab, and enter the applicant’s information into the required form. When an applicant is approved, HE will issue a program-specific confirmation document that grants immediate temporary eligibility, along with instructions for eligible applicants to complete the application process. CHDP applicant enrollment through the Point of Service (POS) device will not change.

With this change, previous provider manual instructions on how to enroll applicants will be updated, as follows:

Provider Training
Provider training for HE registration and applicant enrollment for the BCCTP, Hospital PE and CHDP programs is now available on the Medi-Cal Learning Portal. The training includes the following subject matter:

More information about HE is available on the Medi-Cal System Replacement: CA-MMIS Health Enterprise Web page, which can be accessed via the Hot News area on the Medi-Cal website.

Providers are also encouraged to watch for HE updates in the NewsFlash area on the Medi-Cal website, and subscribe to the Medi-Cal Subscription Service (MCSS) to receive timely notifications related to HE by completing the MCSS Subscriber Form on the Medi-Cal website. Providers with questions or concerns may call the Telephone Service Center (TSC) POS/Internet Helpdesk at 1-800-541-5555 from 6 a.m. to midnight, Monday through Friday, except holidays.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (7)
Inpatient Services hospital presum (1, 3)
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3. 2015 CPT-4/HCPCS Annual Update: Manual Replacement Page Release

The 2015 updates to the Current Procedural Terminology - 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2015 CPT-4/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 will be effective for dates of service on or after October 1, 2015. Please refer to the 2015 CPT-4 and HCPCS Level II code books for complete descriptions of these codes.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program medi non hcp (1–3)
Audiology and Hearing Aids medi non hcp (1–3); tax (6)
Chronic Dialysis Clinics blood (2, 3); immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non cpt (1, 2); medi non hcp (1–3); modif used (4, 5, 8, 9); non inject (8); path bil (1, 6, 14, 15); path organ (6, 9); vaccine (3, 7, 8)
Clinics and Hospitals blood (2, 3); cardio (5, 7, 8, 10); chemo drug a-d (5); chemo drug e-o (16); chemo drug p-z (1, 6); dental (1); eval (16, 24, 25); fam planning (7); immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non cpt (1, 2); medi non hcp (1–3); medne (14); medne neu (8); medne oto (4); modif used (4, 5, 8, 9); non inject (8); non ph (10, 11, 20–22); once (5); path bil (1, 6, 14, 15); path drug (1–6); path micro (5); path molec (8, 28, 30); path organ (6, 9); path surg (1, 2, 4); presum (19-23, 25); radi (8); radi dia (23, 24); radi dia ult (1); radi onc (1, 2, 6, 8); surg bil mod (7); surg cardio (2, 6, 9, 11); surg digest (5); surg eye (13); surg muscu (7, 9–12); surg urin (6); tar and non cd2 (1, 2, 4); tar and non cd3 (4, 5, 7); tar and non cd4 (2, 5–7); tar and non cd5 (3); tar and non cd6 (1, 2); tar and non cd7 (3); tar and non cd8 (1–4); tar and non cd9 (1, 4, 6, 9); transplant (8); vaccine (3, 7, 8)
Durable Medical Equipment dura (12); dura bil inf (4); dura bil wheel (6); dura cd (26, 35, 39, 43); dura cd fre (1, 4); medi non hcp (1–3); ortho cd1 (30); ortho cd2 (10, 19); ortho cd fre1 (4); ortho cd fre2 (2, 3); tax (6)
General Medicine blood (2, 3); cardio (5, 7, 8, 10); chemo drug a-d (5); chemo drug e-o (16); chemo drug p-z (1, 6); dental (1); eval (16, 24, 25); fam planning (7); immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non cpt (1, 2); medi non hcp (1–3); medne (14); medne neu (8); medne oto (4); modif used (4, 5, 8, 9); non inject (8); non ph (10, 11, 20–22); once (5); path bil (1, 6, 14, 15); path drug (1–6); path micro (5); path molec (8, 28, 30); path organ (6, 9); path surg (1, 2, 4); presum (19-23, 25); radi (8); radi dia (23, 24); radi dia ult (1); radi onc (1, 2, 6, 8); surg bil mod (7); surg cardio (2, 6, 9, 11); surg digest (5); surg eye (13); surg muscu (7, 9–12); surg urin (6); tar and non cd2 (1, 2, 4); tar and non cd3 (4, 5, 7); tar and non cd4 (2, 5–7); tar and non cd5 (3); tar and non cd6 (1, 2); tar and non cd7 (3); tar and non cd8 (1–4); tar and non cd9 (1, 4, 6, 9); transplant (8); vaccine (3, 7, 8)
Heroin Detoxification medi non hcp (1–3)
Home Health Agencies/Home and Community-Based Services medi non hcp (1–3)
Hospice Care Program medi non hcp (1–3)
Inpatient Services medne (14); tar and non cd2 (1, 2, 4); tar and non cd3 (4, 5, 7); tar and non cd4 (2, 5–7); tar and non cd5 (3); tar and non cd6 (1, 2); tar and non cd7 (3); tar and non cd8 (1–4); tar and non cd9 (1, 4, 6, 9); transplant (8)
Local Educational Agency dental (1)
Medical Transportation medi non hcp (1–3)
Obstetrics dental (1); eval (16, 24, 25); fam planning (7); immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non cpt (1, 2); medi non hcp (1–3); modif used (4, 5, 8, 9); non inject (8); non ph (10, 11, 20–22); once (5); path bil (1, 6, 14, 15); path drug (1–6); path micro (5); path molec (8, 28, 30); path organ (6, 9); path surg (1, 2, 4); presum (19-23, 25); radi (8); radi dia (23, 24); radi dia ult (1); radi onc (1, 2, 6, 8); surg bil mod (7); surg urin (6); tar and non cd2 (1, 2, 4); tar and non cd3 (4, 5, 7); tar and non cd4 (2, 5–7); tar and non cd5 (3); tar and non cd6 (1, 2); tar and non cd7 (3); tar and non cd8 (1–4); tar and non cd9 (1, 4, 6, 9); vaccine (3, 7, 8)
Orthotics and Prosthetics dura cd (26, 35, 39, 43); dura cd fre (1, 4); medi non hcp (1–3); ortho cd1 (30); ortho cd2 (10, 19); ortho cd fre1 (4); ortho cd fre2 (2, 3); tax (6)
Pharmacy blood (2, 3); dura (12); dura bil inf (4); dura bil wheel (6); dura cd (26, 35, 39, 43); dura cd fre (1, 4); immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non hcp (1–3); ortho cd1 (30); ortho cd2 (10, 19); ortho cd fre1 (4); ortho cd fre2 (2, 3); presum (19-23, 25); tax (6)
Psychological Services medi non hcp (1–3); psychol cd (1)
Rehabilitation Clinics immun (8–10); immun cd (1); inject cd list (2, 3, 7–9, 12–15, 17); inject drug e-h (2, 6, 16, 25); medi non hcp (1–3); modif used (4, 5, 8, 9); non inject (8); non ph (10, 11, 20–22); vaccine (3, 7, 8)
Therapies dura cd (26, 35, 39, 43); dura cd fre (1, 4); medi non hcp (1–3); ortho cd1 (30); ortho cd2 (10, 19); ortho cd fre1 (4); ortho cd fre2 (2, 3)
Vision Care contact lens (4, 6); eye app (2, 9); eyeglass lens (3, 8); medi non cpt (1, 2); medi non hcp (1–3); modif used vc (4); rates max eye app (9); tar comp vc (2)
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4. New Benefit for Alternative Birthing Centers

Effective for dates of service on or after October 1, 2015, the following CPT-4 Evaluation and Management (E&M) codes are reimbursable when services are provided in an Alternative Birthing Center (ABC).

CPT-4 Code Description
99234

Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date with requires these three key components:

  • a detailed or comprehensive history;
  • a detailed or comprehensive examination; and
  • medical decision making that is straightforward or of low complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the presenting problem(s) requiring admission are of low severity. Typically 40 minutes are spent at the bedside and on the patient's hospital floor or unit

99235

Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components:

  • a comprehensive history;
  • a comprehensive examination; and
  • medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

99236

Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components:

  • a comprehensive history;
  • a comprehensive examination; and
  • medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the presenting problem(s) requiring admission are of high severity. Typically, 55 minutes are spent at the bedside and on the patient's floor or unit.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
altern (2)
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5. EWC Program Services Updates

Effective for dates of service on or after October 1, 2015, the following CPT-4 codes are added as benefits of Every Woman Counts (EWC):

CPT-4 Code Description
76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete
76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited
87624 Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), high-risk types
88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (list separately in addition to code for primary procedure)

The following CPT-4 codes are deleted as benefits of Every Woman Counts (EWC):

CPT-4 Code Description
76645 Ultrasound, breast(s), (unilateral or bilateral), real time with image documentation
87621 Papillomavirus, human, amplified probe technique

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (16, 17, 21, 23)
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6. PE Program Expanded to Include the Removal of IUDs

Effective for dates of service on or after October 1, 2015, CPT-4 code 58301 (removal of intrauterine device [IUD]) is reimbursable as a benefit of the Presumptive Eligibility (PE) progra

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (19)
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7. HCPCS Code for Management of Breast Cancer Treatment to Become Non-Benefit

Effective October 1, 2015, HCPCS code S3854 (gene expression profiling panel for use in the management of breast cancer treatment) is a non-benefit. Beginning October 1, 2015, providers should bill with CPT-4 code 81519 (oncology [breast], mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score) in place of HCPCS code S3854.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics path bil (15)
Clinics and Hospitals
General Medicine
Obstetrics
path bil (15); once (1)
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8. Unapproved Prescription Otic Products No Longer Reimbursable

Effective for dates of services on or after December 1, 2015, Medi-Cal pharmacy claims for prescription unapproved otic products that contain the above listed ingredients will no longer be reimbursed. These claims will reject, even with a valid Treatment Authorization Request (TAR) or Service Authorization Request (SAR).

The United States Food and Drug Administration (FDA) released an article titled “FDA takes action against unapproved prescription ear drop products” on July 1 2015, announcing its intention to take enforcement action against companies that manufacture and/or distribute certain unapproved prescription ear drop products (known as otic products) labeled to relieve ear pain, infection and inflammation. The unapproved prescription ear drops contain active ingredients such as benzocaine and hydrocortisone, and have not been evaluated by the FDA for safety, effectiveness and quality. The agency informed the affected companies that they must stop manufacturing these unapproved prescription otic products or be subject to enforcement actions, including seizure, injunction and/or criminal proceedings. This action does not affect FDA approved prescription otic products or legally marketed otic products sold over-the-counter.

Unapproved prescription otic drug products containing the following ingredients are covered by this action:

According to the FDA, unapproved prescription otic drug products are frequently given to young children suffering from ear infections and other conditions that cause ear pain and swelling. Patients taking unapproved drugs may be at greater risk because there is no proven safety or effectiveness information. These products may be contaminated or manufactured incorrectly, which could result in patients receiving the wrong dose, even when administered according to the labeled directions for use. For more information on the FDA’s decision, refer to the Unapproved and Misbranded Otic Prescription Drug Products; Enforcement Action Dates Web page of the Federal Register website.

For information about prescription covered products and program coverage, refer to Drugs: Contract Drugs List Part 1 – Prescription Drugs sections of the Contract Drugs List Pharmacy manual.

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9. Drug Safety Communication: NSAIDs Increase Chance of Heart Attack or Stroke

A new DUR Educational Article titled “Drug Safety Communication: NSAIDs Increase Chance of Heart Attack or Stroke” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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10. Pharmacy Network Restriction Removed on Naltrexone Long Acting Injection

Effective for dates of service on or after June 16, 2015, Vivitrol (naltrexone long acting injection) can be obtained with an approved Treatment Authorization Request (TAR) from any contracted pharmacy for Medi-Cal beneficiaries. The use of a specialty pharmacy network is no longer required.

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11. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
September 1, 2015 BUPRENORPHINE/NALOXONE Administration added, strength added, restriction added drugs cdl p1a (26)
September 1, 2015 EZETIMIBE Restriction changed drugs cdl p1b (13)
November 1, 2015 LEVONORGESTREL Restriction changed drugs cdl p1b (54)
November 1, 2015 MORPHINE SULFATE Administration changed, restriction changed drugs cdl p1b (73)
November 1, 2015 SEVELAMER HYDROCHLORIDE Administration removed drugs cdl p1d (2)
December 1, 2015 ANTIPYRINE AND BENZOCAINE Restriction added drugs cdl p1a (14)
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12. Diagnosis Code Requirement Policy Update for HIV Testing

Effective for dates of service on or after October 1, 2015, CPT-4 codes 87389 (HIV-1 antigen[s], with HIV-1 and HIV-2 antibodies, single result) and 87390 (HIV-1) may be billed with any ICD-10-CM diagnosis code.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path bil (1)
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13. Alcohol Laboratory Test Becomes Benefit

Effective for dates of service on or after October 1, 2015, HCPCS code G6040 (alcohol [Ethanol]; any specimen except breath) is a benefit. The code may (not must) be billed with modifier QW (CLIA waived test). The code must not be reported in conjunction with CPT-4 code 80320 (alcohols).

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path bil (6)
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14. Koate-DVI Products Require a TAR or SAR

Effective retroactively for dates of service on or after August 1, 2015, Koate-DVI products require an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). Koate-DVI products are billed under code J7190 (Factor VIII [antihemophilic factor, human], per IU).

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

Provider Manual(s) Page(s) Updated
General Medicine
Chronic Dialysis Clinics
Clinics and Hospitals
Pharmacy
blood (2)
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15. Correction: Aqueous Shunt is a Non-Benefit

CPT-4 code 66183 (insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach) has been corrected in the provider manual to describe its status as a non-benefit.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Inpatient Services
tar and non cd6 (4)
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16. CPT-4 Code 36515 is No Longer a Medi-Cal Benefit

Effective for dates of service on or after October 1, 2015, CPT-4 code 36515 (therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion) is no longer a Medi-Cal benefit.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
tar and non cd3 (6)
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17. Update to Medi-Cal Notes to Rates Page

New procedure type “Q” for mental health expansion and local code conversion for psychology has been added to the Medi-Cal Notes to Rates Web page:

Q Psychology Services for Mental Health Expansion
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18. Reimbursement Rates Increased for Various Speech Evaluation CPT-4 Codes

Effective for dates of service on or after October 1, 2015, the reimbursement rates have been increased up to 80 percent of the Medicare rate for the following CPT-4 codes:

CPT-4 Code Description
92521 Evaluation of speech fluency (eg, stuttering, cluttering)
92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
92523
with evaluation of language comprehension and expression (eg, receptive and expressive language)
92524 Behavioral and qualitative analysis of voice and resonance

Providers may view the updated reimbursement rates on the Medi-Cal Rates page of the Medi-Cal website.
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19. TAR Required for Denosumab

Effective for dates of service on or after October 1, 2015, HCPCS code J0897 (injection, denosumab, 1 mg) will require a Treatment Authorization Request (TAR) for reimbursement. Also, documenting ICD-9-CM diagnosis code restrictions is no longer required.

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

Provider Manual(s) Page(s) Updated
General Medicine
Chronic Dialysis Clinics
Clinics and Hospitals
Obstetrics
Pharmacy
Rehabilitation Clinics
inject drug a-d (24, 25)
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20. October 2015 Medi-Cal Provider Seminar

The next Medi-Cal Provider Seminar is scheduled for October 13, 2015, at the Red Lion Hotel, Redding, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP), clicking the seminar date(s) they would like to attend, and RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the Fiscal Intermediary for Medi-Cal, Xerox State Healthcare, LLC, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

In addition, 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 are encouraged to bookmark the Provider Training page and refer to it often for current seminar information.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative 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 your Regional Representative you must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request contact by a representative.
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21. Provider Orientation

Family PACT

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code, Section 24005(k). The Family PACT Provider Orientation provides an overview of the Family PACT program, provider enrollment process, program standards and benefits, and client eligibility and enrollment. Certificates of Attendance are issued at the end of the session. The certificates are issued only to the following attendees:

Provider Orientation Highlights

Upcoming Provider Orientations

Oakland
October 6, 2015
8:30 a.m. – 4:30 p.m.
The California Endowment Center
1111 Broadway, 7th Floor
Oakland, CA 94607
Los Angeles
December 1 and 2, 2015
Two Orientations
8:30 a.m. – 4:30 p.m.
The California Endowment Center
1000 North Alameda
Los Angeles, CA 90012

For more information about Provider Orientations, please call (916) 324-0389.

Registration
The registration form should be submitted in an electronic format.

To register for an Orientation providers should:

If you experience problems using the “Submit by Email” button, please fax the registration form to (916) 440-5634 or send it as an attachment to ProviderServices@dhcs.ca.gov.

Check-In
Check-in begins at 8:00 a.m. At the Orientation, site certifiers must present a photo identification. Xerox State Healthcare, LLC field representatives will be available for questions on billing and claims.

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

Certificate of Attendance
Upon completion of the Orientation, the site certifier will receive a copy of the Certificate of Attendance if the service site is enrolled in Medi-Cal. The original certificate will be retained by the Office of Family Planning. Multiple sites may be certified at a single Orientation; however, the site certifier must sign a separate certificate for each service site to be enrolled.

Contact Information
For more information about the Family PACT program, please call 1-800-942-1054 or visit the Family PACT website.

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22. 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 for urgent announcements and other updates shortly, after posting 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
  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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