Medi-Cal Update

General Medicine | December 2018 | Bulletin 534

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1. 2019 CPT Annual Update

The 2019 updates to the Current Procedural Terminology (CPT) codes are available in the 2019 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

For Specialty Programs, current or future benefits for updated CPT codes are reflected in the following PDF documents:

The code additions, changes and deletions are effective for dates of service on or after January 1, 2019. Please refer to the 2019 CPT code book for complete descriptions of these codes.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Long Term Care
Medical Transportation
Therapies
Vision Care
opt ben exc (7)
Chronic Dialysis Clinics inject cd list (9); modif used (4)
Clinics and Hospitals
General Medicine
anest (13); cardio (8–10); eval (16, 22, 28, 29); ev woman (21, 22, 34, 35); inject cd list (9); modif used (4); non ph (9, 10, 23, 24); once (6, 7); opt ben exc (7); path molec (3–15, 19–22, 25–27, 30–36, 39, 40, 46, 60, 61); presum bill (10); radi (3); radi dia (9, 24); radi dia ult (4); rates max (5); spec (2); surg bil mod (7, 8); surg nerv (4, 5); surg urin (3, 6); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Inpatient Services opt ben exc (7); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Local Educational Agency loc ed bil cd (7); loc ed bil ex (12, 14); loc ed serv psych (6)
Obstetrics anest (13); eval (16, 22, 28, 29); ev woman (21, 22, 34, 35); inject cd list (9); modif used (4); non ph (9, 10, 23, 24); once (6, 7); opt ben exc (7); path molec (3–15, 19–22, 25–27, 30–36, 39, 40, 46, 60, 61); presum bill (10); radi (3); radi dia (9, 24); radi dia ult (4); rates max (5); surg bil mod (7, 8); surg urin (3, 6); tar and non cd1 (1); tar and non cd2 (1, 4); tar and non cd3 (5, 7, 8); tar and non cd4 (1, 4); tar and non cd5 (1, 4); tar and non cd6 (3, 4); tar and non cd7 (2, 3); tar and non cd8 (1, 4); tar and non cd9 (4, 6–9)
Pharmacy inject cd list (9); opt ben exc (7); presum bill (10)
Psychological Services opt ben exc (7); psychol (4–7, 9); psychol cd (2); spec (2)
Rehabilitation Clinics inject cd list (9); modif used (4); non ph (9, 10, 23, 24); opt ben exc (7)
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2. October 2018 HCPCS Quarterly Update: Policy Updates

The October 2018 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the Quarter 4 HCPCS Policy (Medi-Cal) PDF. Only those codes representing Medi-Cal benefits effective October 1, 2018, are included in the list of updates.

Please refer to the 2018 HCPCS Level II code book for complete descriptions of these codes.

Providers should refer to the HCPCS Annual Update page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18)
Clinics and Hospitals
General Medicine
chemo drug e-o (6–8); chemo drug p-z (4); inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13); ophthal (16)
Durable Medical Equipment dura bil wheel (19); dura cd (28)
Orthotics and Prosthetics
Therapies
dura cd (28)
Obstetrics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13)
Pharmacy dura bil wheel (19); dura cd (28); inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18)
Rehabilitation Clinics inject cd list (5, 6, 13); inject drug a-d (52); inject drug e-h (3, 16–18); non ph (12, 13)
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3. Every Woman Counts Cervical Cancer Screening Update

Effective for dates of service on or after August 20, 2018, the Every Woman Counts (EWC) program includes primary human papillomavirus (HPV) testing as a screening strategy for women 30 to 65 years of age. The program recommends using the American Society for Colposcopy and Cervical Pathology (ASCCP) and the Society of Gynecologic Oncology (SGO) guidelines for follow up after primary HPV testing, including coverage for HPV genotyping, billed with CPT code 87625 (infectious agent detection by nucleic acid [DNA and RNA]; Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed). An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

U.S. Preventive Services Task Force (USPSTF) posted updated recommendations on screening average-risk women for cervical cancer. The USPSTF recommends that clinicians screen for cervical cancer in women 21 to 29 years of age every three years with the Pap test alone. For women 30 to 65 years of age, the USPSTF recommends screening either with the Pap test alone every three years, screening with the high-risk HPV test alone (primary HPV testing) every five years or screening with both tests together (co-testing) every five years. Women should talk to their clinician to choose which strategy is right for them. The USPSTF continues to recommend against screening in women younger than 21 years of age and in women older than 65 years of age who have had adequate prior screening. For more information, providers may refer to the Final Recommendation Statement page of the USPSTF website.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (9, 27)
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4. Every Woman Counts Program Addition of New Data Entry Fields for DETEC

Effective for dates of service on or after January 2, 2019, the Every Woman Counts (EWC) Program will implement two new data entry fields in the EWC data entry applications known as DETEC (DETecting Early Cancer) for High Risk for Breast Cancer and High Risk for Cervical cancer. The collection of this data is required by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) of the Center for Disease Control and Prevention (CDC).

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5. Clarification of EWC DETEC ‘Lost to Follow-up’ and ‘Refused Care’ Statuses

The DETEC (DETecting Early Cancer) “lost to follow-up” and “refused care” statuses for the Every Woman Counts (EWC) program are clarified as follows.

DETEC “Lost to Follow-up” Status
Recipients are considered to have a “lost to follow-up” status if they require immediate diagnostic work but cannot be reached because 1) they do not reside at the stated address and 2) their phone is disconnected or they can no longer be reached via the stated phone number.

Providers should document three or more attempts to contact the recipient in the recipient’s medical record, including documenting that a sent, certified letter was undeliverable and returned. Documentation that a certified letter was sent is not sufficient. Recipients are not considered “lost to follow-up” if they can be located.

DETEC “Refused Care” Status
Recipients are considered to have a “refused care” status if they require immediate diagnostic work but the recipient does one of the following:

Providers should document three or more attempts to contact the recipient in the recipient’s medical record, including documenting a reason for refused care and that a certified letter was sent.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (17)
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6. EContra Emergency Contraceptives Reimbursable for Medi-Cal and Family PACT

Effective retroactively for dates of service on or after March 1, 2018, National Drug Codes (NDCs) for EContra emergency contraceptive drugs are reimbursable under HCPCS code J3490 U6 for the Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) programs.

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

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7. EPSDT Psychology, Mental & Behavioral Health Code Conversion: TAR/SAR Policy

Effective for dates of service on or after April 1, 2019, the Department of Health Care Services (DHCS) will discontinue HCPCS Level III local codes for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health services. These codes will be replaced by HIPAA-compliant CPT Category I national codes, used by Medicare, to comply with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000.

To view the full code conversion, including relevant additional instructions, refer to the crosswalk on the EPSDT Services: Psychology, Mental and Behavioral Health section of the HIPAA: Code Conversions web page.

Providers should prepare and submit Treatment Authorization Requests (TARs)/electronic TARs (eTARs) or Service Authorization Requests (SARs)/electronic SARs (eSARs) according to the following instructions:

TAR/eTAR Conversion Policy
Effective for dates of service on or after April 1, 2019, new TARs/eTARs for EPSDT psychology, mental and behavioral health services must include CPT Category I national codes. TARs/eTARs using the HCPCS Level III local codes will only be valid for dates of service ending on or before March 31, 2019.

TARs/eTARs Previously Approved, Retroactive and Deferred
Existing TARs/eTARs with HCPCS Level III local codes, regardless of status (approved, retroactive or deferred), will be invalid and providers will need to end-date TARs/eTARs for dates of service beyond March 31, 2019. Providers will need to submit new TARs/eTARs with the appropriate CPT Category I national code(s) for services on or after April 1, 2019.

TARs/eTARs Submitted After April 1, 2019
All TARs/eTARs submitted on or after April 1, 2019, that require authorization beyond this date must include only CPT Category I national codes.

Providers are strongly encouraged to use eTARs. Provider benefits when using eTARs include: no mail delays or postage, money savings and quicker response time. Additionally, eTARs allow providers to check the status of their TAR at any time. For additional information, providers should look for an upcoming eTAR seminar in their area or call the Telephone Service Center (TSC) at 1-800-541-5555.

Guidelines for TAR/eTAR submissions are located in the appropriate Part 1 provider manual.

SAR/eSAR Conversion Policy
Effective for dates of service on or after April 1, 2019, new SARs/eSARs for EPSDT psychology, mental and behavioral health services must include CPT Category I national codes. SARs/eSARs using the HCPCS Level III local codes will only be valid for dates of service ending on or before March 31, 2019.

SARs/eSARs Previously Authorized with Through Dates Beyond March 31, 2019
Existing SARs/eSARs authorized for dates of service beyond March 31, 2019, must be end-dated. Providers should review their existing EPSDT psychology, mental and behavioral health SARs/eSARs that extend beyond March 31, 2019; and submit a new SAR/eSAR with the appropriate CPT Category I national code(s) to cover any remaining service period after March 31, 2019. At the same time, providers should request existing SARs/eSARs with the HCPCS Level III local codes be end-dated effective March 31, 2019.

SARs/eSARs Submitted After April 1, 2019
Effective for dates of service on or after April 1, 2019, providers may begin requesting SARs/eSARs with CPT Category I national codes. SARs/eSARs using the HCPCS Level III local codes may be submitted only for dates of service ending on or before March 31, 2019. SARs/eSARs with HCPCS Level III local codes received after April 1, 2019, may be denied.

Providers may need to resubmit SARs/eSARs with the appropriate CPT Category I national codes.

eSARs now accept attachments. California Children's Services (CCS) and Genetically Handicapped Persons Program (GHPP) 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 guidance and additional information.

Additional information for this code conversion will publish as details are determined.

Providers are encouraged to watch for EPSDT psychology, mental and behavioral health services 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.

Providers may also request additional onsite or telephone support via the TSC at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Providers calling from outside of California can contact TSC at (916) 636-1200.

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8. EPSDT Psychology, Mental and Behavioral Health Services Code Conversion: FAQs

Effective for dates of service on or after April 1, 2019, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health services code conversion will replace HCPCS Level III local codes with HIPAA-compliant CPT Category I national billing codes. EPSDT Psychology, Mental and Behavioral Health Services Code Conversion Frequently Asked Questions (FAQs) are available.

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9. EPSDT Psychology, Mental & Behavioral Health Code Conversion: Technical Support

Effective for dates of service on or after April 1, 2019, the Department of Health Care Services (DHCS) will discontinue HCPCS Level III local codes for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) psychology, mental and behavioral health services. These codes will be replaced by HIPAA-compliant CPT Category I national codes, used by Medicare, to comply with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000.

Providers and submitters who bill for EPSDT psychology, mental and behavioral health services using the ANSI 837P and 837I transactions for electronic billing are encouraged to visit the Testing and Activation Procedures section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual.

Submitters may test status to ensure accurate file format, completeness and validity for HIPAA-compliant claims transactions by logging into the Medi-Cal test site using their submitter ID and password. Instructions for CMC testing is located in the Testing and Activation Procedures section of the CMC Billing and Technical Manual.

CMC evaluates the test file and determines if the following requirements have been met for all format types:

Note:

A new test must be submitted when software is upgraded or the submission method changes.

For electronic claim submission questions, contact the Telephone Service Center (TSC) at 1 800-541-5555, select option “4” for the Technical Help Desk and option “2” for CMC.

For additional information, providers may:

Providers are encouraged to watch for EPSDT psychology, mental and behavioral health services 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.

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10. Reimbursement Updates for Select Chronic Care Management Services Codes

Effective for dates of service on or after January 1, 2019, HCPCS code G0506 (comprehensive assessment of and care planning for patients requiring chronic care management services) is reimbursable to practitioners who furnish a Chronic Care Management (CCM)-initiating visit and personally perform extensive assessment and CCM care planning beyond the usual effort described by the initiating visit code. HCPCS code G0506 has a frequency limit of once per provider, per lifetime.

In addition, reimbursement for CPT code 99490 (chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month…) assumes 15 minutes of work by the billing practitioner. Only one practitioner can be reimbursed for CPT code 99490 per calendar month.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (28)
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11. Notice of HIPAA Code Conversion for Maternal Care Services and CPSP

The maternal care services and Comprehensive Perinatal Service Program (CPSP) code conversion replaces HCPCS Level III codes, commonly referred to as local codes, with HIPAA-compliant CPT Category I or HCPCS Level II national codes. HIPAA mandated these changes to the billing requirements for maternal care services and CPSP providers.

For claims with dates of service on or after April 1, 2019, providers will use a combination of revenue codes and CPT Category I or HCPCS Level II codes; or revenue codes and CPT Category I or HCPCS Level II codes with a modifier.

Billing instructions and Frequently Asked Questions (FAQs) will soon be available in the Maternal Care Services and CPSP section located on the HIPAA: Code Conversions web page.

Providers are encouraged to:

Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers call (916) 636-1200. Providers calling from outside of California call the Out-of-State Provider Unit at (916) 636-1960.

For electronic claim submission questions, contact the TSC at 1-800-541-5555, select option “4” for the Technical Help Desk and option “2” for Computer Media Claims (CMC).

Submit all other questions about the maternal care services and CPSP code conversion via email to CAMMISCodeConversion@conduent.com.

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12. Maternal Care Services and CPSP Code Conversion: Technical Publications and Support

Effective for dates of service on or after April 1, 2019, the Department of Health Care Services (DHCS) will discontinue HCPCS Level III local codes for maternal care services and Comprehensive Perinatal Services Program (CPSP). These codes will be replaced by HIPAA-compliant CPT Category I and HCPCS Level II national codes, used by Medicare, to comply with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000.

Maternal care and CPSP providers using the ANSI 837P and 837I transactions for electronic billing are encouraged to visit the Testing and Activation Procedures section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual.

Submitters may test status to ensure accurate file format, completeness and validity for HIPAA-compliant claims transactions by logging into the Medi-Cal test site using their submitter ID and password. Instructions for CMC testing is located in the Testing and Activation Procedures section of the CMC Billing and Technical Manual.

CMC evaluates the test file and determines if the following requirements have been met for all format types:

Note:

A new test must be submitted when software is upgraded or the submission method changes.

For electronic claim submission questions, contact the Telephone Service Center (TSC) at 1-800-541-5555, select option “4” for the Technical Help Desk and option “2” for CMC.

For additional information, providers may:

Providers are encouraged to watch for maternal care and CPSP 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 maternal care and CPSP services.

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13. Maternal Care Services and CPSP Code Conversion Webinars Begin in February

Medi-Cal providers have the opportunity to attend free online webinars pertaining to the maternal care services and Comprehensive Perinatal Services Program (CPSP) code conversion effective April 1, 2019.

Webinars are presented live and begin at 10:00 a.m. on the following dates:

Webinars are accessible through the Medi-Cal Learning Portal (MLP). First-time webinar attendees must complete the registration prior to attending. Once registered, view the webinar schedule and RSVP for training on the Provider Training Calendar. Workbooks are emailed to attendees approximately 24-72 hours in advance of the webinar.

For additional information, providers may:

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14. Maternal Care Services and CPSP Code Conversion: TAR/eTAR Policy Update

Effective for dates of service on or after April 1, 2019, the Department of Health Care Services (DHCS) will discontinue HCPCS Level III local codes for maternal care services and Comprehensive Perinatal Services Program (CPSP). These codes will be replaced by HIPAA-compliant CPT Category I and HCPCS Level II national codes, used by Medicare, to comply with provisions of the 1996 Public Law 104-191, 45 CFR 162.1000.

To view the full code conversion, including relevant additional instructions, refer to the billing instructions on the HIPAA: Code Conversions web page under the Maternal Care Services and CPSP heading.

Providers should prepare and submit Treatment Authorization Requests (TARs)/electronic TARs (eTARs) according to the following instructions:

TAR/eTAR Conversion Policy
Effective for dates of service on or after April 1, 2019, new TARs/eTARs for maternal care services and CPSP must include CPT Category I or HCPCS Level II national codes. TARs/eTARs using the HCPCS Level III local codes will only be valid for dates of service ending on or before March 31, 2019.

TARs/eTARs Previously Approved, Retroactive and Deferred
Existing TARs/eTARs with HCPCS Level III local codes, regardless of status (approved, retroactive or deferred), will be invalid and providers will need to end-date TARs/eTARs for dates of service authorized beyond March 31, 2019. Providers will need to submit new TARs/eTARs with the appropriate CPT Category I or HCPCS Level II national code(s) for services on or after April 1, 2019.

TARs/eTARs Submitted After April 1, 2019
All TARs/eTARs submitted on or after April 1, 2019, that require authorization beyond this date must include only CPT Category I or HCPCS Level II national codes.

Guidelines for TAR/eTAR submissions are located in the appropriate Part 1 provider manual.

Providers are strongly encouraged to use eTARs. Provider benefits when using the eTAR include no mail delays or postage, money savings and quicker response time. Additionally, eTARs allow providers to check the status of their TAR at any time. Providers should look for an upcoming eTAR seminar in their area and RSVP on the Provider Training Calendar web page.

Additional information for this code conversion will publish as details are determined. Providers are encouraged to watch for maternal care services and CPSP updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update provider bulletins. Providers should complete the Medi-Cal Subscription Service (MCSS) Form to receive timely notifications related to maternal care services and CPSP.

Providers may also request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Providers calling from outside of California can contact TSC at (916) 636-1200.

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15. Provider Readiness Checklist: Maternal Care Services and CPSP

The intent of the Provider Readiness Checklist is to provide a general guide only to assist in the seamless transition from HCPCS Level III Codes to HIPAA-compliant national codes. As a suggestion, providers are encouraged to integrate the following activities into their daily routine to prepare for and comply with the requirements for the Maternal Care Services and Comprehensive Perinatal Services Program (CPSP) code conversion. This change will impact claims with dates of service on or after the policy effective date of April 1, 2019.

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16. Notice of HIPAA Code Conversion for NICU/PICU Services

The Neonatal and Pediatric Intensive Care Unit (NICU/PICU) code conversion replaces HCPCS Level III codes, commonly referred to as local codes, with HIPAA-compliant CPT Category I national codes. HIPAA mandated these changes to the billing requirements for NICU/PICU services.

For claims with dates of service on or after May 1, 2019, providers will use HIPAA-compliant CPT Category I codes with or without modifier(s).

Billing Instructions and Frequently Asked Questions (FAQs) will soon be available in the NICU/PICU Services section of the HIPAA: Code Conversions web page. Additional information for this project will publish as details are determined.

Providers are encouraged to:

Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers call (916) 636-1200. Providers calling from outside of California call the Out-of-State Provider Unit at (916) 636-1960.

For electronic claim submission questions, contact the TSC at 1-800-541-5555, select option “4” for the Technical Help Desk and option “2” for Computer Media Claims (CMC).

All other questions about the NICU/PICU code conversion may be submitted via email to CAMMISCodeConversion@conduent.com

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17. Sign Language Interpreter Services Code Conversion Policy Overview

Effective for dates of service on or after January 1, 2019, sign language interpreter services currently billed using HCPCS Level III local codes will be converted to a specified HCPCS Level II national code.

Providers submitting claims with dates of service on or after January 1, 2019, must include the appropriate HIPAA-compliant HCPCS Level II national code described in the Sign Language Interpreter Services Crosswalk published October 2018.

For dates of service on or after January 1, 2019, HCPCS Level III local codes Z0324, Z0326, Z0328 and Z0329 will be discontinued, and any claims submitted with these codes will be denied. HCPCS Level III local codes Z0324 and Z0326 will be replaced by HCPCS Level II national code T1013 (sign language or oral interpretive services, per 15 minutes) and revenue code 0969 (other professional fees) for UB-04 claim forms or ANSI 837I transactions.

Modifier code HM (less than bachelor degree level) will be applicable when billing for sign language interpreter services for dates of service on or after January 1, 2019. Modifier code HM is used to denote that the rendering provider is a certified sign language interpreter.

Provider Resources
Providers should refer to the Miscellaneous Services section of the HIPAA: Code Conversions web page for a complete list of sign language interpreter services code conversion resources.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Adult Day Health Care Centers
Chiropractic
Heroin Detoxification
Hospice Care Program
Inpatient Services
Long Term Care
Multipurpose Senior Services Program
Pharmacy
Psychological Services
sign (3)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
modif app (11); modif used (12); non ph (11, 24); sign (3)
Chronic Dialysis Clinics modif app (11); modif used (12); sign (3)
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
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 (11); sign (3)
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18. Prenatal Care for Medi-Cal Recipients with OHC is Subject to Cost Avoidance

In accordance with the Bipartisan Budget Act of 2018, Section 53102, prenatal care services are subject to cost avoidance. If the cost for prenatal care services cannot be differentiated from labor and delivery, the entire claim will be cost avoided.

A recipient is required to use their OHC prior to their Medi-Cal coverage when the same service is available under the recipient’s OHC. When a service or procedure is not a covered benefit of the recipient’s OHC, a copy of the original denial letter or Explanation of Benefits (EOB) is acceptable for the same recipient and service for a period of one year from the date of the original denial letter or EOB.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Expanded Access to Primary Care Program
Heroin Detoxification
Hospice Care Program
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Rehabilitation Clinics
oth hlth cpt (3)
Clinics and Hospitals
General Medicine
Obstetrics
oth hlth cpt (3); preg glo (4); preg per (2); preg post (1)
Home Health Agencies/Home and Community-Based Services oth hlth cpt (3); preg post (1)
Inpatient Services preg post (1)
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19. 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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20. EPSDT Psychology, Mental and Behavioral Health Code Conversion Reminder

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.

For claims with dates of service on or after April 1, 2019, providers will use a combination of:

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 for the EPSDT Psychology, Mental and Behavioral Health Code Conversion may be submitted via email to CAMMISCodeConversion@conduent.com.

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21. Naloxone HCl Available to Bystanders At Risk of Witnessing Opioid Overdose

Effective for dates of service on or after October 1, 2018, naloxone HCl is a covered pharmacy benefit for Medi-Cal beneficiaries at risk of experiencing an opioid overdose and for beneficiaries at risk of witnessing an opioid overdose as a bystander. This policy is consistent with California Civil Code, Section 1714.22, and applies to pharmacy claims submitted under the order of a licensed prescriber or when naloxone HCl is furnished by pharmacists under the statewide protocol pursuant to California Business and Professions Code, Section 4052.01.

Further information about pharmacists furnishing naloxone HCl to Medi-Cal beneficiaries under statewide protocol can be found in an article titled “Pharmacist Furnishing of Medications under Statewide Protocol” in the May 2018 Medi-Cal Update.

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22. Buprenorphine Extended-Release Injection Authorized by Specialty Pharmacy

Effective for dates of service on or after October 1, 2018, the buprenorphine extended-release injection is available as a pharmacy benefit through a select network of authorized pharmacies with an approved Treatment Authorization Request (TAR).

The address and contact information of the current network pharmacy authorized to provide this benefit are listed below:

Avella Specialty Pharmacy
2288 Auburn Boulevard, Suite 102
Sacramento, CA  95821-1619

Telephone: 1-888-792-3888
Fax: 1-888-554-3299

For more information regarding the buprenorphine extended-release injection pharmacy benefit, providers may refer to the Physician-Administered Drugs section in the Pharmacy manual.

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23. 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
September 17, 2018 DORAVIRINE Drug added, administration added, restrictions added drugs cdl p1a (64)
September 17, 2018 DORAVIRINE/ LAMIVUDINE/ TENOFOVIR DISOPROXIL FUMARATE Drug added, administration added, restrictions added drugs cdl p1a (65)
October 1, 2018 BINIMETINIB Drug added, administration added, restrictions added drugs cdl p1a (23)
October 1, 2018 ENCORAFENIB Drug added, administration added, restrictions added drugs cdl p1b (4)
October 15, 2018 DACOMITINIB Drug added, administration added, restrictions added drugs cdl p1a (51)
October 31, 2018 MOXETUMOMAB PASUDOTOX-TDFK Drug added, administration added, restrictions added drugs cdl p1b (78)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
December 1, 2018 RIMEXOLONE Restriction added drugs cdl p1c (48)
January 1, 2019 COLCHICINE Administration added, restriction added drugs cdl p1a (48)
February 1, 2019 COLCHICINE Administration changes, restriction added, note added drugs cdl p1a (48)
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24. 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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25. 2019 Medi-Cal Provider Training Schedule

The 2019 Medi-Cal provider training schedule is now available. Providers can access Medi-Cal training information and registration details by clicking on the Outreach & Education slideshow area of the Medi-Cal website homepage or by visiting the Training Calendar web page of the Medi-Cal Learning Portal (MLP).

Training Date Webinar or Seminar Location Address
January 2 – 31 Webinar Information posted on the Medi-Cal website
February 13 – 14 Seminar Concord
Crowne Plaza
45 John Glenn Drive
Concord, CA  94520
March 13 – 14 Seminar Ontario
Ontario Airport Hotel & Conference Center
700 North Haven Ave.
Ontario, CA  91764
April 17 Seminar Redding
Red Lion Hotel Redding
1830 Hilltop Drive
Redding, CA  96002
May 15 – 16 Seminar Escondido
California Center For The Arts
340 N. Escondido Blvd.
Escondido, CA  92025
June 4 – 27 Webinar Information to be posted on the Medi-Cal website
July 17 – 18 Seminar Sacramento
Sheraton Grand Sacramento Hotel
1230 J Street
Sacramento, CA  95814
August 14 – 15 Seminar Long Beach
Long Beach Marriott
4700 Airport Plaza Drive
Long Beach, CA  90815
September 17 – 18 Seminar Visalia
Visalia Convention Center
303 E. Acequia Ave.
Visalia, CA  93291
October 29 – 30 Seminar Pasadena
Pasadena Convention Center
300 E. Green Street
Pasadena, CA  91101
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26. January 2019 Medi-Cal Provider Training Webinars

Beginning January 2, 2019, and continuing throughout the month of January, Medi-Cal providers may participate in provider training webinars:

Providers will be able to print class materials and ask questions during the training sessions. Recorded webinars will be archived and available for on-demand viewing from the MLP.

To view the webinars, providers must have Internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal website.

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27. February 2019 Medi-Cal Provider Seminar

The February Medi-Cal provider seminar is scheduled for February 13 – 14, 2019, at the Crown Plaza in Concord, 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 the DHCS Fiscal Intermediary (FI) 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 January 30, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After January 30, 2019, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks 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 representative.

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

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28. 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

Oakland
February 13, 2019
10:00 a.m. – 2:00 p.m.
California Endowment
2000 Franklin Street
Oakland, CA  94612

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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29. 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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30. 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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31. 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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32. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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