Medi-Cal Update

General Medicine | August 2017 | Bulletin 518

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2. 2017 CPT-4/HCPCS Annual Update: Policy Updates

The 2017 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 2017 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 are effective for dates of service on or after October 1, 2017. Please refer to the 2017 CPT-4 and HCPCS Level II code books for complete descriptions of these codes. Manual replacement pages reflecting these changes will be released in a future Medi-Cal Update.

Additionally, the 2017 CPT-4 codebook was updated to allow separate reimbursement for moderate (conscious) sedation for multiple codes that had previously included moderate (conscious) sedation as an inherent part of providing the procedure. Please refer to the 2017 CPT-4 codebook for instructions on how to bill for this service with other codes.

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3. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically
  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 278 transactions
    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 278 transactions

Registered providers, clearinghouses or Managed Care Plans can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (1, 12); genetic (4, 5)
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4. Face-to-Face Encounter Required for DME Prescription

Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to allow reimbursement to providers only for Durable Medical Equipment (DME) items that are signed for by a physician in either written or electronic format. Additionally, a face-to-face encounter administered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, related to the primary reason the recipient requires the DME item, is also required. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (1, 4, 5); dura bil dme (3, 9, 10, 14, 22, 25); dura bil oxy (12); dura bil thp (11)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (3, 12)
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5. Revision to Diagnosis Codes for Eye and Ocular Adnexa Surgery

Effective retroactively for dates of service on or after October 1, 2015, CPT-4 codes 65778 (placement of amniotic membrane on the ocular surface; without sutures) and 65779 (…single later, sutured) are reimbursable when with billed with ICD-10-CM diagnosis code B00.50 and are not reimbursable when with billed with the following ICD-10-CM diagnosis codes:

H10.89 H16.269
H16.261 T81.32XA
H16.262 T81.32XD
H16.263 T81.32XS

Additionally, claims processing issues are corrected for the following CPT-4 and ICD-10-CM diagnosis code combinations when billed in accordance with previously published policy.

A claims processing issue was identified that may cause claims to erroneously deny when CPT-4 codes 66820 (discission of secondary membranous cataract [opacified posterior lens capsule and/or anterior hyaloid]; stab incision technique [Ziegler or Wheeler knife]) and 66821 (…laser surgery [eg, YAG laser] [1 or more stages]) are billed with the following ICD-10-CM diagnosis codes:

T85.21XD
T85.21XS
T85.22XD
T85.22XS
T85.29XD
T85.29XS

Another claims processing issue was identified that may cause claims to erroneously deny when CPT-4 codes 65778 and 65779 are billed with the following ICD-10-CM diagnosis codes:

L12.1 T26.12XS T26.32XS T26.52XS T26.72XS T26.92XS
T26.00XD T26.20XD T26.40XD T26.60XD T26.80XD T81.31XD
T26.00XS T26.20XS T26.40XS T26.60XS T26.80XS T81.31XS
T26.01XD T26.21XD T26.41XD T26.61XD T26.81XD T81.33XD
T26.01XS T26.21XS T26.41XS T26.61XS T26.81XS T81.33XS
T26.02XD T26.22XD T26.42XD T26.62XD T26.82XD
T26.02XS T26.22XS T26.42XS T26.62XS T26.82XS
T26.10XD T26.30XD T26.50XD T26.70XD T26.90XD
T26.10XS T26.30XS T26.50XS T26.70XS T26.90XS
T26.11XD T26.31XD T26.51XD T26.71XD T26.91XD
T26.11XS T26.31XS T26.51XS T26.71XS T26.91XS
T26.12XD T26.32XD T26.52XD T26.72XD T26.92XD  

An Erroneous Payment Correction will be issued to reprocess affected claims.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
surg eye (11)
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6. New Update: PE4PW Computer Based Training Instructions

An amended NewsFlash article published on May 8, 2017, titled Correction: PE4PW Computer Based Training Instructions Revised contained corrective actions for providers to perform in the Medi-Cal Learning Portal (MLP).

A recent update to the MLP system now allows only newly qualified PE4PW providers that have registered properly, using a valid NPI and selecting user type “Healthcare Provider” or “Provider Staff,” to see the link to the Computer Based Training (CBT) course “Presumptive Eligibility for Pregnant Women (PE4PW) Program Provider Training Course.”

Providers who are not registered in MLP using a valid NPI and under either Healthcare Provider or Provider Staff user types will no longer be able to see the link to the PE4PW training course in MLP.

Accessing the Training
The computer must pass a connectivity test for providers to access the training.

Providers should:

Providers who are unsure what user type is associated with their account, or who know their user type needs to be changed, should contact the Telephone Service Center (TSC) at 1-800-541-5555 and select Option 4 and then Option 2. A TSC agent will verify whether information is correct and, if necessary, submit a request to update the user profile. User profiles should be updated within 48 hours. Once a profile is updated, the provider can complete the CBT.

Failure to update user profiles to include appropriate user types will delay providers’ ability to help applicants apply for temporary Medi-Cal coverage via the automated PE4PW application.

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7. Medi-Cal List of Contract Drugs

The following provider manual section(s) has been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs.

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.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
August 1, 2017 MORPHINE SULFATE/NALTREXONE Drug added, restriction added, administration added, strength added drugs cdl p1b (74)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
May 1, 2017 ENZALUTAMIDE Restriction added drugs cdl p1b (5)
May 30, 2017 TRASTUZUMAB Strength added drugs cdl p1d (20)
June 12, 2017 MARAVIROC Administration added, strength added drugs cdl p1b (61)
July 19, 2017 RALTEGRAVIR Strength added drugs cdl p1c (39)
August 1, 2017 DUTASTERIDE Restriction removed drugs cdl p1a (65)
August 1, 2017 MOMETASONE FUROATE MONOHYDRATE Restriction added drugs cdl p1b (72)
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8. Updated Address and Telephone Number for Placer County Mental Health Services

The address for the Placer County Mental Health Services is updated as follows:

Placer County Mental Health Services
Attn: TAR Processing Unit
11512 B Avenue
Auburn, CA 95603

The telephone and fax numbers are updated as follows:

Telephone Number Fax Number
(530) 886-2929 (530) 886-2940

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Psychological Services
spec cnty (6)
Inpatient Services inp ment pln (5)
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9. September 2017 Medi-Cal Provider Seminar

The September Medi-Cal provider seminar is scheduled for September 26 – 27, 2017, at the Ontario Convention Center in Ontario, California. Providers can access a class schedule for the seminar by visiting the Provider Training 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 the DHCS Fiscal Intermediary 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 September 12, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After September 12, 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 web 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 regional representative.

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

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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