Medi-Cal Update

General Medicine | March 2017 | Bulletin 513

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1. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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2. Update: DHCS Fiscal Intermediary Name Change

Effective immediately, providers may notice that the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) for the Medi-Cal program, formerly Xerox State Healthcare, LLC (Xerox), is operating under a new company name, “Conduent.” Providers may also see the Conduent logo on some items.

Operations and interactions with providers are not impacted by this FI name change.

Providers may see this name change in items such as:

  • NewsFlash articles and Medi-Cal Update bulletins
  • Medi-Cal website (www.medi-cal.ca.gov)
  • Forms and User Guides
  • Provider Manuals
  • Medi-Cal Learning Portal (MLP)
  • Presentations at Provider Training Seminars
  • Provider Letters, such as Erroneous Payment Corrections (EPCs)
  • Additional hard copy correspondence
  • Emails with an “@conduent.com” address rather than an “@xerox.com” address
  • References to the Conduent name when researching mailing addresses or published telephone numbers
Conduent logo

There are no changes in the telephone numbers used by providers, including the Telephone Service Center (TSC) number (1-800-541-5555), as a result of this name change. The mailing addresses used by providers to conduct business with DHCS and the FI will remain the same.

Medi-Cal providers are strongly encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles, and System Status Alerts. Providers may sign up for MCSS by visiting http://www.medi-cal.ca.gov and completing the MCSS Subscriber Form. For more information about Conduent, visit https://www.conduent.com.

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3. Extended Deadline of the Streamlined Procedure for ACA-Related Appeals

The filing period for submission of Patient Protection and Affordable Care Act-related (ACA) appeals is extended from June 30, 2016, to December 31, 2017. The deadline has been extended to assist providers in completing all their ACA-related appeals.

The Streamlined Procedure for ACA-Related Appeals published February 23, 2016, details the submission of appeals regarding ACA payments for Medi-Cal services. Providers should closely follow the article's instructions in all regards except for the filing deadline.

Providers with questions may call the Telephone Service Center at 1-800-541-5555.

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4. PE for Pregnant Women Automation Effective April 1, 2017

Effective April 1, 2017, the application process for Qualified Providers (QPs) in the Presumptive Eligibility for Pregnant Women (PE4PW) program, which is used to help applicants apply for interim Medi-Cal services, is automated. QPs are encouraged to begin using the automated Presumptive Eligibility for Pregnant Women Program Application (MC 263), which will be available in the Transactions area of the Medi-Cal website. QPs will be able to use the MC 263-P (paper) form to gather the applicant's information prior to inputting it in the automated system. The MC 263-P is available in both English and Spanish.

Note:

The current paper application process using form MC 263 version 06/2016 will remain available for six months (through September 29, 2017) to ensure all providers have time to transition to the new process. After that date, paper MC 263 forms will not be used/available.

Provider Manual Update: Helping Patients Qualify for Temporary Medi-Cal
The new Presumptive Eligibility for Pregnant Women Program Process manual section contains the automated process instructions providers follow to help patients apply for temporary Medi-Cal (and all other health insurance affordability programs), pending a final eligibility determination.

Provider Manual Update: Provider Enrollment
Additionally, the new Presumptive Eligibility for Pregnant Women Provider Enrollment Instructions section and associated form, Presumptive Eligibility for Pregnant Women Provider Enrollment Checklist, contain instructions to help providers enroll as PE4PW providers.

PE for Pregnant Women Forms
Many of the forms listed on the Presumptive Eligibility for Pregnant Women Web page of the Medi-Cal website will remain in use for dates April 1, 2017 through September 29, 2017. Due to automation, after that date the following forms will no longer be used/available:

The older version of the provider enrollment form MC 311 (version 10/07) will be removed from the website and substituted with a newer version (Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility for Pregnant Women (PE4PW) Program [version 12/16]) on both the Presumptive Eligibility for Pregnant Women Web page and the Forms Web page.

References
For more details about form MC 263 automation and MC 311 changes, providers may refer to the Presumptive Eligibility for Pregnant Women Frequently Asked Questions and the February 2017 bulletin article Automation of PE for Pregnant Women Program. For questions about the PE4PW program, providers may contact the Medi-Cal Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, except holidays, as follows:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
gene coun (2); preg determ (1); preg early (1); presum (1); presum proc (1–7); presum prov (1–5); presum prov enroll frm (1)
Pharmacy pcf30-1 spec (6); presum (1); presum proc (1–7); presum prov (1–5); presum prov enroll frm (1)
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5. Licensed Midwives Can Now Perform Obstetrical Services Independently

Effective retroactively for dates of service on or after July 1, 2015, licensed midwives (LMs) are authorized to enroll independently as Medi-Cal providers and perform obstetrical services without supervision of a licensed physician or surgeon pursuant to California Code of Regulations ( CCR), Title 16, Sections 1379.19, 1379.20, 1379.22 and 1379.30. LMs may submit claims to the Department of Health Care Services (DHCS) for services rendered, excluding Comprehensive Perinatal Services Program services where LMs can only be employed as contract service providers.

In compliance with HIPAA, DHCS has authorized the use of modifier U9 as the exclusive modifier to identify services rendered by an LM. The following CPT-4 and HCPCS codes may be submitted for reimbursement by an LM when billed with modifier U9.

CPT-4 Code Definition
31500 Intubation, endotracheal, emergency procedure
51701 Insertion of non-indwelling bladder catheter (eg, straight catheterization of residual urine)
59300 Episiotomy or vaginal repair, by other than attending
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care
59409 Vaginal delivery only (with or without episiotomy and/or forceps);
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
96361     each additional hour
99070 Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered
99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant
99461 Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn
99465 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output

HCPCS Code Definition
Z1032 Initial comprehensive pregnancy-related office visit
Z1034 Antepartum visit
Z1038 Postpartum visit

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology
Durable Medical Equipment
Chronic Dialysis Care
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (18)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (26, 27); modif app (18)
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6. New Medi-Cal Benefit for Abdominal Ultrasound Services

Effective for dates of service on or after October 1, 2016, HCPCS code C9744 (ultrasound, abdominal, with contrast) is a new Medi-Cal benefit.

Code C9744 is reimbursable with an approved Treatment Authorization Request (TAR) and may be billed in conjunction with modifiers U7 (Medicaid level of care 7) and 99 (multiple modifiers). This service is reimbursable for the treatment of both male and female recipients and may be performed by a non-medical practitioner (NMP).

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Rehabilitation Clinics
modif used (11)
Clinics and Hospitals
General Medicine
Obstetrics
modif used (11); radi dia ult (3)
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7. Policy Update: ECMO/ECLS Age Groups

Effective retroactively for dates of service on or after January 1, 2015, Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Life Support (ECLS) procedures will cover all ECMO/ECLS codes for all age groups (0 – 5 years of age and 6 – 99 years of age).

The following CPT-4 codes are Medi-Cal benefits for ECMO/ECLS procedures that will cover all age groups (0 – 5 years of age and 6 – 99 years of age):

CPT-4 Code Description
33946 Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947 initiation, veno-arterial
33948 daily management, each day, veno-venous
33949 daily management, each day, veno-arterial
33951 insertion of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33953 insertion of peripheral cannula(e), open, birth through 5 years of age
33955 insertion of peripheral cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33957 reposition of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33959 reposition of peripheral cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33963 reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33965 removal of peripheral cannula(e), percutaneous, birth through 5 years of age
33969 removal of peripheral cannula(e), open, birth through 5 years of age
33985 removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33987 Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS
33988 Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
33989 Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

In order to perform ECMO/ECLS for infants, the institution must be a California Children’s Services (CCS) approved Neonatal Intensive Care Unit (NICU) as both a regional NICU and an ECMO center. The institution must also be capable of providing inhaled nitric oxide services for neonates for children.

In order to perform ECMO for recipients awaiting lung transplantation, the institution must be a Medi-Cal approved Center of Excellence for lung transplantation and have performed ECMOs on adults for a minimum of three years and performed an average of five ECMOs per year.

Daily overall management of the recipient may be separately reported using the relevant hospital inpatient services or critical care evaluation and management codes (99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 and 99480) and may be reimbursed to any provider, same recipient and same date of service.

Services must be submitted on the claim with all revenue/sick baby codes applicable to the entire stay. An infant claim must be submitted for services rendered to the baby only. Care for the mother is billed separately.

The following are revenue codes for ECMO services provided to newborns, infants and children, and adults:

Revenue Code Description
174 Nursery, Newborn; Level IV (newborn 0-28 days)
202 Intensive Care, Medical (adults)
203 Intensive Care, Pediatric (infants and children)

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Rehabilitation Clinics
modif used (11)
Clinics and Hospitals
General Medicine
medne (4–7); modif used (11); tar and non cd3 (5, 6)
Inpatient Services medne (4–7); tar and non cd3 (5, 6)
Obstetrics modif used (11); tar and non cd3 (5, 6)
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8. Two Local EWC Infusion and Solution Codes Replaced

Effective for dates of service on or after April 1, 2017, the following HCPCS codes are no longer reimbursable for Every Woman Counts (EWC) program services:

HCPCS Code Description
X7700 Administered intravenous solution; initial, up to 1000 ml, including related supplies
X7702 each additional 1000 ml, including related supplies

Effective for dates of service on or after April 1, 2017, the following HCPCS codes are reimbursable for EWC program services:

HCPCS Code Description
J7030 Infusion, normal saline solution, 1000 cc
J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit)
J7050 Infusion, normal saline solution, 250 cc
J7120 Ringers lactate infusion, up to 1000 cc

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (29)
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9. Update to Newborn Screening Rates

Effective April 1, 2017, the rate for HCPCS code S3620 (newborn metabolic screening panel, includes test kit, postage and the following tests: hemoglobin; electrophoresis; hydroxyprogesterone; 17-D; phenalanine [PKU]; and thyroxine, total) is retroactively updated for two periods of service.

Effective Dates of Service Previous Medi-Cal Rate Updated Medi-Cal Rate
January 1, 2012 –
June 30, 2016
$102.75 $112.70
July 1, 2016 $112.70 $130.25

The rate that is effective for dates of service on or after July 1, 2016, is the current rate for HCPCS code S3620.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

For more information providers may refer to the Medi-Cal Rates Web page on the Medi-Cal website.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
rates max (7)
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10. HCPCS Codes Added and Terminated for Blood Factors

Effective for dates of service on or after January 1, 2017, the following blood factors are billable with their corresponding HCPCS code:

HCPCS code Description
C9140 Injection, factor VIII (antihemophilic factor, recombinant), (Afstyla), 1 IU
J7175 Injection, factor X, (human), 1 IU *
J7179 Injection, von Willebrand factor (recombinant), (Vonvendi), 1 IU *
J7202 Injection, factor IX, albumin fusion protein (recombinant), Idelvion, 1 IU
J7207 Injection, factor VIII, (antihemophilic factor, recombinant), PEGylated, 1 IU *
J7209 Injection, factor VIII antihemophilic factor, recombinant) (Nuwiq), 1 IU
* Authorization is required

The following HCPCS codes are terminated and no longer billable:

HCPCS code Description
C9137 Injection, factor VIII (antihemophilic factor, recombinant) PEGylated, 1 IU
C9138 Injection, factor VIII (antihemophilic factor, recombinant) (Nuwiq), 1 IU

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
blood (2, 3); non ph (10, 11, 22, 23)
Chronic Dialysis Clinics
Pharmacy
blood (2, 3)
Obstetrics
Rehabilitation Clinics
non ph (10, 11, 22, 23)
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11. Improving the Quality of Care: Risks Associated with Use of Fluoroquinolones

A new DUR Educational Article titled “Improving the Quality of Care: Risks Associated with Use of Fluoroquinolones” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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12. Psychotropic Drug Age Restriction Policy Reminder

Effective January 1, 2017, age restrictions have been placed on non-antipsychotic psychotropic medications reflecting the minimum age for which medication has been FDA-approved. The current age restrictions on antipsychotic medications will remain in place. Claims for psychotropic medications which do not meet the age restriction criteria require an approved Treatment Authorization Request (TAR).

Providers are reminded that claims for unlabeled (off-label) use of medications always require an approved TAR. Title 22 of the California Code of Regulations states the following:

22 CCR § 51313
(4) Authorization for unlabeled use of drugs shall not be granted unless the requested unlabeled use represents reasonable and current prescribing practices. The determination of reasonable and current prescribing practices shall be based on:
(A) Reference to current medical literature.
(B) Consultation with provider organizations, academic and professional specialists.

The term “off-label usage” applies to any use of a medication in a manner not specifically approved by the FDA and delineated on the label given to the drug during the approval process.

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13. Medi-Cal List of Contract Drugs

The following provider manual sections have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs.

A summary of drugs that have been changed are 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
January 1, 2017 EPINEPHRINE Restriction changed drugs cdl p1b (5)
January 1, 2017 LEVONORGESTREL Restriction added drugs cdl p2 (10)
March 1, 2017 NORETHINDRONE ACETATE AND ETHINYL ESTRADIOL Restriction removed drugs cdl p1c (7)
April 1, 2017 ALECTINIB Restriction added drugs cdl p1a (4)
April 1, 2017 ATEZOLIZUMAB Restriction added drugs cdl p1a (17)
April 1, 2017 AXITINIB Restriction added drugs cdl p1a (18)
April 1, 2017 COBIMETINIB Restriction added drugs cdl p1a (46)
April 1, 2017 DENILEUKIN DIFTITOX Restriction added drugs cdl p1a (53)
April 1, 2017 ELVITEGRAVIR/
COBICISTAT/
EMTRICITABINE/
TENOFOVIR DISOPROXIL FUMARATE
Restriction added drugs cdl p1b (2)
April 1, 2017 EVEROLIMUS Restriction added drugs cdl p1b (12)
April 1, 2017 NILOTINIB Restriction added drugs cdl p1c (5)
April 1, 2017 PERTUZUMAB Restriction added drugs cdl p1c (25)
April 1, 2017 VEMURAFENIB Restriction added drugs cdl p1d (26)
April 1, 2017 VISMODEGIB Restriction added drugs cdl p1d (28)
May 1, 2017 FENOFIBRATE, MICRONIZED Restriction added drugs cdl p1b (15)
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14. Intravenous Solution Codes X7700 and X7702 Terminated

Effective for dates of service on or after April 1, 2017, intravenous solution codes X7700 (administered intravenous solution; initial, up to 1000 ml, including related supplies) and X7702 (…each additional 1000 ml, including related supplies) are terminated.

Effective for dates of service on or after April 1, 2017, the following HCPCS codes are reimbursable for intravenous solutions.

HCPCS code Description
J7030 Infusion, normal saline solution, 1000 cc
J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit)
J7042 5% dextrose/normal saline solution (500 ml = 1 unit)
J7050 Infusion, normal saline solution, 250 cc
J7060 5% dextrose/water (500 ml = 1 unit)
J7070 Infusion, D5W, 1000 cc
J7120 Ringer's lactate infusion, up to 1,000 cc

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

Provider Manual(s) Page(s) Updated
Acupuncture
Adult Day Health Care Centers
Chiropractic
Expanded Access to Primary Care Program
Inpatient
Local Educational Agencies
Multipurpose Senior Services Program
hcpcs iii (1, 2)
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Orthotics and Prosthetics
Psychological Services
Therapies
hcpcs iii (1, 2); medi non hcp (1)
Chronic Dialysis Clinics
Rehabilitation Clinics
hcpcs iii (1, 2); medi non hcp (1); supp drug (1, 2)
Clinics and Hospitals
General Medicine
Obstetrics
anest (9); hcpcs iii (1, 2); medi non hcp (1); supp drug (1, 2)
Pharmacy
Vision
medi non hcp (1)
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15. April 2017 Medi-Cal Provider Seminar

The next Medi-Cal seminar is scheduled for April 25 – 26, 2017, at the Long Beach Marriott in Long Beach, California. Providers can access a class schedule for the seminar by visiting the Provider Training Web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

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

Providers must register by April 11, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 11, 2017, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks Web page of the Medi-Cal website.

Note:  Wi-Fi will not be provided at the seminar, please plan accordingly.

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 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 a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a representative.

Providers are encouraged to bookmark the Provider Training Web page and refer to it often for current seminar information.

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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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