Medi-Cal Update

General Medicine | November 2018 | Bulletin 533

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1. Corrected Reimbursement Rates for Select HCPCS Codes

Effective retroactively for dates of service on or after February 1, 2018, the Department of Health Care Services (DHCS) updates reimbursement rates for HCPCS codes S1090 (mometasone furoate sinus implant, 370 micrograms) and J7296 (levonorgestrel-releasing intrauterine contraceptive system, [Kyleena], 19.5 mg) to $795 and $908.97, respectively. The reimbursement rate for both codes was previously $0.

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

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2. Diabetes Prevention Program: New Medi-Cal Benefit Coming in 2019

Effective for dates of service on or after January 1, 2019, the Diabetes Prevention Program (DPP) will be a Medi-Cal covered benefit.

Medi-Cal’s program will be consistent with the federal Centers for Disease Control and Prevention’s (CDC’s) guidelines and will also incorporate many components of the Centers for Medicare & Medicaid Services’ (CMS’) DPP in Medicare.

Medi-Cal providers choosing to offer DPP services must comply with CDC guidance and obtain CDC recognition in connection with the National Diabetes Prevention Recognition Program. Medi-Cal’s DPP will include a core benefit consisting of at least 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. In addition, participants who achieve and maintain a required minimum weight loss of 5 percent from the first core session will also be eligible to receive ongoing maintenance sessions, after the 12-month core services period, to help them continue healthy lifestyle behaviors. The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

Additional Information
Detailed coverage and reimbursement policy will be released in a future Medi-Cal Update. For additional important information concerning the DPP, providers are encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to the upcoming changes. Providers may sign up for MCSS by completing the MCSS Subscriber Form.

Questions and comments may be emailed to DHCSDPP@dhcs.ca.gov.

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3. Cervical Cancer Screening and HPV Testing Updates and USPSTF Recommendations

Effective for dates of service on or after December 1, 2018, CPT codes 87624 (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], high-risk types) and 87625 (…Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed) are reimbursable with modifier 33. Use of modifier 33 indicates the service was provided in accordance with a U.S. Preventive Services Task Force (USPSTF) A or B recommendation. In addition, any ICD-10-CM diagnosis code may be used.

For cervical cancer screening, USPSTF recommends screening for cervical cancer every three years with cervical cytology alone in women 21 to 29 years of age. For women 30 to 65 years of age, USPSTF recommends screening every three years with cervical cytology alone, every five years with high-risk human papillomavirus (hrHPV) testing alone or every five years with hrHPV testing in combination with cytology (co-testing).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path micro (6)
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4. Family PACT Update: Copper IUC Reimbursable as a Pharmacy Benefit

Effective for dates of service on or after September 1, 2018, the copper intrauterine contraceptive (ParaGard T 380A) is reimbursable as a Family Planning, Access, Care and Treatment (Family PACT) pharmacy benefit. For additional information, providers may refer to the Physician-Administered Drugs section in Part 2 Medi-Cal Pharmacy provider manual.

Pharmacy-dispensed ParaGard T 380A is solely sourced by the ParaGard Specialty Pharmacy. For contact information, providers may refer to the ParaGard website. For ordering information, providers may refer to the PARAGARD Specialty PharmacySM section on the Welcome to the ParaGard Program website.

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

Provider Manual(s) Page(s) Updated
Family PACT pharmacy (4, 13)
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5. Policy Clarification: Retroactive Eligibility Period for EWC Recipients

Claims for services provided prior to but within 30 days of the recipient certification date on the Every Woman Counts (EWC) recipient’s recipient identification card are eligible for reimbursement. The recipient certification date is the first date in the date range that is listed in the data field labeled “Valid:” on the recipient ID card.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (12)
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6. Clarification on Which Special Programs May Bill EWC

Providers who render services for the following special programs are reminded that they may bill only as an Every Woman Counts (EWC) Primary Care Provider using an NPI number that is actively enrolled, and must submit claims according to EWC guidelines. These special programs cannot submit claims as a referring provider.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (5)
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7. Depression Screenings for Select Recipients Are Now Reimbursable

Effective for dates of service on or after December 1, 2018, depression screening is reimbursable under Medi-Cal as an outpatient service. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment options including referral to mental health specialists and appropriate follow-up.

Billing Codes
The following chart lists procedure codes that must be used when billing for depression screening:

Recipient Category Positive Depression Screen Negative Depression Screen
Pregnant or postpartum G8431 with
modifier HD
G8510 with
modifier HD
Age 12 and older, not pregnant or postpartum G0444 with
modifier KX
96127

Pregnant or Postpartum Recipients
Providers of prenatal care and postpartum care may submit claims twice per year per pregnant or postpartum recipient: once when the recipient is pregnant and once when she is postpartum. Screens that are positive for depression must be billed using HCPCS code G8431 (screening for depression is documented as being positive and a follow-up plan is documented) and modifier HD. Screens that are negative for depression must be billed using HCPCS code G8510 (screening for depression is documented as negative, a follow-up plan is not required) and modifier HD.

Postpartum Depression Screening at Well-Child Visits
Providers of well-child care may submit claims for a maternal depression screening up to four times during the infant's first year of life. Bright Futures recommends screening for maternal depression at the infant's one-month, two-month, four-month and six-month visits, with referral to the appropriate provider for further care if indicated. Screens that are positive for depression must be billed using HCPCS code G8431 and modifier HD. Screens that are negative for depression must be billed using HCPCS code G8510 and modifier HD. When a postpartum depression screening is provided at the infant's well-child visit, the screening must be billed using the infant's Medi-Cal ID. The only exception to this policy is that the mother's Medi-Cal ID may be used during the first two months of life if the infant's Medi-Cal eligibility has not yet been established.

Recipients Who Are Not Pregnant or Postpartum
Screening for depression is reimbursable for recipients 12 years of age or older who are not pregnant or postpartum, once per year, per recipient, per provider using HCPCS code G0444 (annual depression screening, 15 minutes) with modifier KX for a positive screen, and CPT code 96127 (brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument) for a negative screen.

Screening Tools
Medi-Cal requires the use of a validated depression screening tool. Some examples include:

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Durable Medical Equipment
Expanded Access to Primary Care Program
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (11)
General Medicine
Clinics and Hospitals
eval (27–30); medne neu (8); modif app (11); non ph (10, 23); preg early (2); preg post (4); presum bill (14); spec (1)
Home Health Agencies/Home and Community-Based Services modif app (11); preg post (4)
Inpatient Services preg post (4)
Obstetrics eval (27–30); modif app (11); non ph (10, 23); preg early (2); preg post (4); presum bill (14)
Pharmacy presum bill (14)
Psychological Services psychol (1); psychol ex (1); spec (1)
Rehabilitation Clinics modif app (11); non ph (10, 23)
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8. Updates to the Lists of Contracted Incontinence Products

Effective for dates of service on or after December 1, 2018, products from the following manufacturers are added to the List of Contracted Incontinence Absorbent Products: Attends Healthcare Products, Inc.; Bandz, Inc.; Essity HMS North American, Inc.; McKesson Medical-Surgical; Medline Industries, Inc.; Secure Personal Care; and Sigma Supply & Distribution, Inc.

Effective for dates of service on or after March 1, 2019, certain products from the following manufacturers are deleted from the List of Contracted Incontinence Absorbent Products and are no longer reimbursable: Attends Healthcare Products, Inc.; Essity HMS North American, Inc.; Secure Personal Care; and Smart Choice Medical.

Effective for dates of service on or after March 1, 2019, the List of Contracted Incontinence Creams and Washes is updated. Products from manufacturer Smart Choice Medical are deleted from the list and are no longer reimbursable.

The maximum acquisition cost (MAC) for products deleted from the lists is no longer guaranteed by the manufacturer.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (10)
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9. EPSDT Psychology, Mental and Behavioral Health Services Code Conversion Reminder

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health services code conversion will replace 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.

Providers are encouraged to watch for EPSDT psychology, mental and behavioral health service updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update.

Providers may complete the Medi-Cal Subscription Service (MCSS) Form to receive timely notifications related to EPSDT psychology, mental and behavioral health services.

For additional information, providers may:

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

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10. Sign Language Interpreter Services Code Conversion Reminder

The sign language interpreter services code conversion will replace HCPCS Level III local codes, commonly referred to as local codes, with HIPAA-compliant HCPCS Level II national codes. This billing requirement for sign language interpreter services is mandated by HIPAA and is effective for claims with dates of service on or after January 1, 2019.

For claims with dates of service on or after January 1, 2019, the sign language interpreter services code conversion will be replacing HCPCS Level III local codes Z0324 and Z0326 with HCPCS Level II national code T1013 (sign language or oral interpretive services, per 15 minutes).

As of January 1, 2019, HCPCS Level III local codes Z0328 and Z0329 used to bill for sign language interpreter services will no longer be reimbursable.

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

Providers are encouraged to watch for sign language interpreter service updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update. Providers may complete the Medi-Cal Subscription Service (MCSS) Form to receive timely notifications related to sign language interpreter services.

For additional information, providers may:

Questions regarding the sign language interpreter services code conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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11. Buprenorphine Extended-Release Injection Added as a Pharmacy Benefit

Effective for dates of service on or after October 1, 2018, the buprenorphine extended-release injection is available as a pharmacy benefit when provided by a specialty pharmacy and with an approved Treatment Authorization Request (TAR).

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1)
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12. Medi-Cal List of Contract Drugs

The following provider manual section(s) have 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.

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2018 BUPRENORPHINE/NALOXONE Strengths added drugs cdl p1a (27)
November 1, 2018 ONDANSETRON Restriction changed, restriction removed drugs cdl p1c (16)
November 1, 2018 QUETIAPINE FUMARATE Restriction removed drugs cdl p1c (43)
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13. Authorized Drug Manufacturer Labeler Codes Update

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

Changes, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
51267 NALPROPION PHARMACEUTICALS
   
Changes, effective May 15, 2018
NDC Labeler Code Contracting Company's Name
00074 ABBVIE INC.
   
Changes, effective July 1, 2018
NDC Labeler Code Contracting Company's Name
15054 IPSEN BIOPHARMACEUTICALS, INC.
   
Terminations, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
00062 ORTHO MCNEIL PHARMACEUTICALS
00064 HEALTHPOINT, LTD.
00149 WARNER CHILCOTT PHARMACEUTICALS INC.
00300 TAP PHARMACEUTICALS INC
00535 FOREST LABORATORIES
10158 GSK CONSUMER HEALTHCARE HOLDINGS (US)LL
11701 COLOPLAST CORPORATION
15749 AMERICAN ANTIBIOTICS, INC.
15821 FOCUS LABORATORIES, INC.
43595 ANGELINI PHARMA, INC.
44946 SANCILIO & COMPANY, INC.
46026 GLOUCESTER PHARMACEUTICAL INC.
46987 ACTAVIS KADIAN LLC
49158 THAMES PHARMACEUTICALS, INC.
49685 NEUROGESX, INC.
50192 NAUTILUS NEUROSCIENCES, INC.
50816 NEW AMERICAN THERAPEUTICS
55390 BEDFORD LABORATORIES
55607 HEALTH SCIENCE FUNDING, LLC
58487 NEW HAVEN PHARMACEUTICALS, INC.
59075 ELAN PHARMACEUTICALS, INC./ATHENA NEURO
62250 BELCHER PHARMACEUTICALS, LLC
62794 MYLAN BERTEK PHARMACEUTICALS, INC.
67467 OCTAPHARMA PHARMAZEUTIKAGM
68209 OCTAPHARMA A.B.
68405 PHYSICIAN THERAPEUTICS LLC
68453 VICTORY PHARMA, INC
68669 VISTAKON PHARMACEUTICAL LLC
69036 SALLUS LABORATORIES, LLC
69150 BIOMES PHARMACEUTICALS, LLC
69158 GLENVIEW PHARMA, INC
69171 MERRIMACK PHARMACEUTICALS, INC.
70147 GLENDALE INC.
70688 KASTLE THERAPEUTICS, INC.
70882 CAMBRIDGE THERAPEUTIC TECHNOLOGIES, LLC
71399 AKRON PHARMA INC.
75989 ACTON PHARMACEUTICALS

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 (2–7, 9–12, 14, 16–20)
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14. 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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15. 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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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. 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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