Medi-Cal Update

General Medicine | October 2018 | Bulletin 532

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1. 2018 ICD-10-PCS Code Annual Update

Effective retroactively for dates of service on or after October 1, 2017, the ICD-10-PCS codes have been updated. Certain ICD-10-PCS codes have been added, deactivated or revised.

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

Information and downloads for these codes can be found on the ICD-10 web page of the CMS website.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
hyst (5); ster (27)
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2. PE4PW: Paper Claim Submission Discontinued and Provider Manual Updates

Effective October 31, 2018, the Department of Health Care Services (DHCS) is discontinuing the manual (paper) enrollment process for assisting individuals to apply for the Presumptive Eligibility for Pregnant Women (PE4PW) program.

PE4PW qualified providers (QPs) who assist individuals to apply should discontinue use of the paper MC 263 Application for Presumptive Eligibility for Pregnant Women Program and shred old unused forms. Providers use, instead, a printable version (MC 263-P) available in English and Spanish in the Transactions area of the Medi-Cal website.

The transition period for existing providers and their staff to move from the manual (paper) process to the previously announced Web Portal electronic enrollment process, expires on October 31, 2018.

Claims submitted with paper MC 263 PE Proof of Eligibility identification cards for dates of service on or after January 1, 2019, will not be reimbursable.

QPs who are not using the electronic real-time enrollment process are encouraged to transition, including participating in required PE4PW computer based training (CBT).

PE4PW Provider Manual Sections Revised
Information about the old paper PE4PW enrollment methods has been removed from the Medi-Cal provider manual. PE4PW provider manual sections and checklist will be as follows:

Section Title Update(s)
Presumptive Eligibility for Pregnant Women Paper process information/forms and billing codes removed. Gender references adapted.
Presumptive Eligibility for Pregnant Women: Billing Codes New section
Presumptive Eligibility for Pregnant Women Program Process No updates
Presumptive Eligibility for Pregnant Women Provider Enrollment Instructions No updates
Presumptive Eligibility for Pregnant Women Provider Enrollment Checklist No updates

Computer Based Training Required
The PE4PW CBT available on the Medi-Cal Learning Portal (MLP) helps newly qualified providers use the automated Presumptive Eligibility for Pregnant Women Program Application (MC 263) to grant immediate, temporary Medi-Cal coverage for applicants who think they are pregnant, and who meet PE4PW program qualifications.

PE4PW participating providers must complete this training before access to the MC 263 is granted.

New MLP users must register to obtain a user account. During MLP registration, the user must select “Healthcare Provider” or “Provider Staff” as the type of user, and provide a National Provider Identifier (NPI) before taking the training.

Existing MLP users must verify their user profile upon log in to ensure the type of user is either “Healthcare Provider” or “Provider Staff” and ensure their NPI is associated with the user account. If the user profile has a type of user other than the two mentioned, the user must update the profile before taking the PE4PW training.

Providers who are not registered in MLP, using a valid NPI and under either Healthcare Provider or Provider Staff user types will not be able to see the link to the PE4PW training course in MLP.

Failure to update user profiles to include appropriate user types will delay providers’ access to the provider training, and their ability to help applicants apply for temporary Medi-Cal via the automated PE4PW application.

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.

Questions
Questions concerning enrollment, computer based training and other PE4PW issues can be sent to PE@dhcs.ca.gov.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (1–7); presum bill (1–15)
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3. Notice of Code Conversion for EPSDT Psychology, Mental and Behavioral Health

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health code conversion replaces non-HIPAA-compliant HCPCS Level III codes commonly referred to as local codes with HIPAA-compliant CPT Category I national codes. HIPAA mandated these changes to billing requirements for EPSDT psychology, mental and behavioral health services.

Providers will use a combination of:

The effective date for this code conversion will be announced at a future date.

EPSDT is a Medi-Cal benefit for individuals younger than 21 years of age who have full-scope Medi Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Treatment services are provided based upon the identified health care need and diagnosis. EPSDT services include all services covered by Medi-Cal. In addition to regular Medi-Cal benefits, recipients younger than 21 years of age may receive additional medically necessary services.

Crosswalks and Frequently Asked Questions (FAQs) will be available soon. Additional information for this project will publish as details are determined.

Providers are encouraged to routinely check the Medi-Cal Update provider bulletins or complete the Medi-Cal Subscription Service (MCSS) Form to receive an email notification for newly published Medi-Cal Update bulletins, Newsflash articles and/or System Status Alerts.

For additional information, providers may:

All other questions for the EPSDT psychology, mental and behavioral health code conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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4. EPSDT Psychology, Mental and Behavioral Health Code Conversion Billing Instructions

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health HCPCS level III local codes Z5800, Z5814, Z5816 and Z5820 will be discontinued. Codes Z5814, Z5816 and Z5820 will be replaced by national HIPAA-compliant CPT Category I codes. The HIPAA-compliant CPT Category I codes will be required on EPSDT psychology, mental and behavioral health claims. Providers submitting UB-04 claim forms or ANSI 837I transactions must bill revenue codes in addition to the national procedure codes.

The effective date for this code conversion will be announced at a future date.

See the EPSDT Psychology, Mental and Behavioral Health Code Conversion Crosswalk for more information. Updated manual pages will be released in a future Medi-Cal Update.

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5. HIPAA Notice of Code Conversion for Sign Language Interpreter Services

Effective for dates of service on or after January 1, 2019, HCPCS Level III local codes Z0324 and Z0326 for sign language interpreter services will be replaced with HIPAA-compliant national HCPCS Level II code T1013. HCPCS Level III local codes Z0328 and Z0329 will be terminated.

Sign language interpreter services are a benefit to facilitate effective communication with deaf or hearing-impaired Medi-Cal recipients. Sign language interpreter services are not covered for recipients receiving these services in a health facility required by law to provide sign language interpreter services.

The Sign Language Interpreter Services Code Conversion Crosswalk and additional information for this project will publish as details are determined.

Providers are encouraged to routinely check the Medi-Cal Update bulletin or complete the Medi-Cal Subscription Service (MCSS) Form to receive an email notification for newly published Medi-Cal Update bulletins, Newsflash articles, and/or System Status Alerts.

For additional information, providers may:

All other questions for the sign language interpreter services code conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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6. Sign Language Interpreter Code Conversion Billing Instructions

Effective for dates of service on or after January 1, 2019, HCPCS Level III local codes Z0324, Z0326, Z0328 and Z0329 for sign language interpreter services will be discontinued. Codes Z0324 and Z0326 will be replaced by national HIPAA-compliant HCPCS Level II code T1013. HCPCS Level II national code T1013 will be required to bill sign language interpreter services. Providers submitting UB-04 claim forms or ANSI 837I transactions must bill revenue codes in addition to national procedure codes. The Sign Language Interpreter Services Code Conversion Crosswalk is available for reference.

Sign language interpreter services are a benefit to facilitate effective communication with deaf or hearing-impaired Medi-Cal recipients. Sign language interpreter services are not covered for recipients receiving these services in a health facility that is required by law to provide sign language interpreter services.

Updated manual pages will be released in a future Medi-Cal Update.

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7. Sign Language Interpreter Services Code Conversion: Frequently Asked Questions

Effective for dates of service on or after January 1, 2019, the sign language interpreter services code conversion replaces HCPCS Level III local codes with HIPAA-compliant HCPCS Level II national billing codes. Providers are encouraged to familiarize themselves with the Sign Language Interpreter Services Code Conversion: Frequently Asked Questions.

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8. Correction: Update to Newborn Screening Rates

The effective date provided in an article titled “Update to Newborn Screening Rates” published in the June 2018 Medi-Cal Update is corrected.

Effective for dates of service on or after July 19, 2018, the rate for HCPCS code S3620 (newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel) is updated to $142.25.

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 page on the Medi-Cal website.

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9. Drug Products Requiring SAR Added for CCS and GHPP

The following drug products are added to the pharmacy list of drugs and nutritional products that require a separate Service Authorization Request (SAR) for the California Children's Services (CCS) program and Genetically Handicapped Persons Program (GHPP).

Retroactive
Effective Date
Drug Product
August 1, 2017 Tisagenlecleucel

Triptorelin pamoate
October 1, 2017 Axicabtagene ciloleucel
November 1, 2017 Emicizumab-KXWH

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Clinics and Hospitals
Chronic Dialysis Clinics
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 (7, 8); genetic (10, 11)
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10. Rate Update for Pathology Service Codes

Effective retroactively for dates of service on or after January 1, 2018, the reimbursement rate for HCPCS code P9037 (platelets, pheresis, leukocytes reduced, irradiated, each unit) is updated.

Effective retroactively for dates of service on or after February 1, 2018, the reimbursement rate for HCPCS code P9073 (platelets, pheresis, pathogen-reduced, each unit) is established.

A list of current rates can be found on the Medi-Cal Rates page of the Medi-Cal website.

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

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11. TPMT Gene Analysis is a New Medi-Cal Benefit

Effective for dates of service on or after November 1, 2018, CPT-4 code 81335 (TPMT [thiopurine S-methyltransferase], gene analysis, common variants) is a Medi-Cal benefit. A Treatment Authorization Request (TAR) is required when billing for the gene analysis. The TAR must document that the patient is undergoing thiopurine therapy and that the patient has severe or prolonged myelosuppression. CPT-4 code 81335 may only be billed once in a lifetime.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (26); tar and non cd8 (2)
Inpatient Services tar and non cd8 (2)
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12. 2018 Immunization Updates: Flu, Tdap, HepB, Zoster, MMR, Adult Vaccines

A new DUR Educational Article titled “2018 Immunization Updates: Flu, Tdap, HepB, Zoster, MMR, Adult Vaccines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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13. Alert: Mandatory Use of CURES 2.0 Begins October 2, 2018

A new DUR Educational Article titled “Alert: Mandatory Use of CURES 2.0 Begins October 2, 2018” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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14. 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.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
July 1, 2018 IRINOTECAN LIPOSOME Drug added, administration added, restrictions added drugs cdl p1b (46)
July 1, 2018 LAMIVUDINE/ TENOFOVIR DISOPROXIL FUMARATE Drug added, administration added, restriction added drugs cdl p1b (50)
July 1, 2018 LANREOTIDE ACETATE Drug added, administration added, restrictions added drugs cdl p1b (51)
July 20, 2018 IVOSIDENIB Drug added, administration added, restrictions added drugs cdl p1b (48)
July 24, 2018 DARUNAVIR/ COBICISTAT/ EMTRICITABINE/ TENOFOVIR ALAFENAMIDE Drug added, administration added, restrictions added drugs cdl p1a (52)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
May 15, 2018 RITONAVIR Restriction changed, administration added drugs cdl p1c (49)
July 1, 2018 HEPATITIS B VIRUS VACCINE Strength added drugs cdl p1b (33)
October 1, 2018 PAZOPANIB HYDROCHLORIDE Restriction added drugs cdl p1c (23)
November 12, 2018 LOMUSTINE Restrictions added drugs cdl p1b (60)
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15. Authorized Drug Manufacturer Labeler Codes Update

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

Additions, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
00990 ICU MEDICAL INC.
36000 BAXTER HEALTHCARE CORPORATION
65628 CUTISPHARMA, INC.
69536 FOUNDATION CONSUMER HEALTHCARE, LLC
70010 GRANULES PHARMACEUTICALS, INC.
70255 ARRAY BIOPHARMA INC.
70621 BIOFRONTERA INC.
71045 ACHAOGEN, INC.
71104 BIOVERATIV US LLC
71334 AGIOS PHARMACEUTICALS, INC.
71428 GLASSHOUSE PHARMACEUTICALS LLC
71930 EYWA PHARMA
76336 HRA PHARMA AMERICA INC.
   
Terminations, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
15310 CREEKWOOD PHARMACEUTICAL, INC.
24477 EKR THERAPEUTICS, INC.
24486 ARISTOS PHARMACEUTICALS, INC.
58181 NEXTSOURCE BIOTECHNOLOGY, LLC
58604 SPROUT PHARMACEUTICALS, INC.
69051 PROFOUNDA, INC.
69654 AYTU BIOSCIENCE, INC.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (5, 7, 8, 12, 15, 18–20)
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16. Electronic SAR Now Supports Attachments

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can now submit Service Authorization Requests (SARs) in an electronic format (eSAR) with attachments. Attachments must be in format of PDF, JPG or TIF. Attachments must be less than 15 megabytes (MB) in size, with the sum of all attachments being less than 150 MB. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit eSARs, providers must:

Then, select one of the available options to submit:

Registered providers and clearinghouses 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 practical reasons to do so.

Providers interested in learning more about eSAR submissions 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 (12); genetic (4)
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17. National Correct Coding Initiative Quarterly Update for October 2018

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are valid for dates of service on or after October 1, 2018.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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18. 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 (W&I Code), Section (§) 24005(k). The Provider Orientation training is delivered online and in person and includes information on comprehensive family planning, program benefits and services, client eligibility, provider responsibilities and compliance.

Each provider's service location is required to be certified for enrollment in the Family PACT Program. Applicants who are enrolled in Medi-Cal and in good standing or are pending Medi-Cal enrollment and who have submitted a Family PACT application packet may complete the Provider Orientation to certify a site for enrollment.

Each service location must designate one eligible representative to be the site certifier. The site certifier cannot certify multiple sites.

The medical director, physician, nurse practitioner or certified nurse midwife who is responsible for overseeing the family planning services rendered at the location to be enrolled is eligible to certify the site.

Provider Orientation details and registration information is posted on the Family PACT website at www.familypact.org.

Upcoming In-Person Orientation

Los Angeles
December 11, 2018
10:00 a.m. – 2:00 p.m.
California Endowment
1000 North Alameda Street
Los Angeles, CA 90012

Please contact the Office of Family Planning by phone (916) 650-0414 or email us at ProviderServices@dhcs.ca.gov if you have any questions regarding the orientation process.

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19. 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 shortly after urgent announcements and other updates post 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 and select a subscriber type

  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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20. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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