Medi-Cal Update

Inpatient Services | February 2016 | Bulletin 497

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1. Mailing Address Update for Paper TAR Submissions

Effective immediately, unless otherwise directed by Medi-Cal, all paper Treatment Authorization Requests (TARs) should be sent to the following location:

TAR Processing Center
820 Stillwater Road
West Sacramento, CA 95605-1630

If a provider submits a TAR to a field office, the TAR will be returned to the provider with instructions to send the TAR to the TAR Processing Center.

For TAR status or issues, providers may call the Telephone Service Center (TSC) at 1-800-541-5555. Providers outside of California may call (916) 636-1980.

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2. AB 97 Dental Services Exemptions

Effective for dates of service on or after July 1, 2015, the following dental services and ancillary services are exempt from the Assembly Bill (AB) 97 10 percent provider payment reduction:

An Erroneous Payment Correction (EPC) will be issued to resolve improperly reimbursed claims.
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3. ICD-10-CM Diagnosis Codes Erroneously Denied for Minor Consent Program Claims

The Department of Health Care Services (DHCS) identified a claims processing issue causing Minor Consent Program claims for the following ICD-10-CM diagnosis codes to erroneously deny:

ICD-10-CM
Code
Description
Z30.014 Encounter for initial prescription of intrauterine contraceptive device
Z30.432 Encounter for removal of intrauterine contraceptive device
Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
Z97.5 Presence of (intrauterine) contraceptive device

DHCS has corrected this issue. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates.

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4. ECMO/ECLS Services Code Conversion and Policy Updates

Effective retroactively for dates of service on or after January 1, 2015, multiple ECMO/ECLS services are added as Medi-Cal benefits. ECMO (Extracorporeal Membrane Oxygenation) is defined as the use of a modified cardiopulmonary bypass circuit for temporary life support for patients with potentially reversible cardiac and/or respiratory failure, also known as Extra Corporeal Life Support (ECLS). ECMO/ECLS provides a mechanism for gas exchange and cardiac support allowing for recovery from existing lung and/or cardiac disease. ECMO/ECLS is an accepted treatment modality for newborns with respiratory and/or cardiac failure unresponsive to conventional medical therapy.

Indications and Selection Criteria
ECMO/ECLS is indicated for but not limited to the following diagnoses:

Selection criteria include all of the following:

TAR/SAR Requirement
An approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) is required for reimbursement of CPT-4 codes 33946 and 33947 only. All other ECMO/ECLS services do not require an approved TAR or SAR.

Physician Services
Neonatology services directly related to the cannulation, initiation, management and discontinuation of the ECMO/ECLS circuit and parameters are distinct from the daily overall management of the patient.

Daily overall management of the patient may be separately reported using the relevant hospital inpatient services, or critical care evaluation and management CPT-4 codes, and may be reimbursed to any provider, same recipient and same date of service. Reference the 2015 Current Procedural Terminology – 4th Edition code book for detailed physician billing instructions for the ECMO/ECLS services for each code.

Inpatient Services
ECMO/ECLS must be performed in a neonatal intensive care unit approved by the California Children’s Services as both a Regional Neonatal Intensive Care Unit (NICU) and an ECMO center.

Code Conversion
The CPT-4 codes listed in the table below replace local HCPCS code Z0312 (ECMO of a single infant performed in an ECMO inpatient unit requiring the continuous personal care and monitoring by an ECMO physician/specialist over a 24-hour period) and represent ECMO/ECLS services. Assistant surgeon services are not payable for these CPT-4 codes

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

*CPT-4 codes 33946 – 33949 are not reimbursable when billed with modifier 63.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (19); medne (4–6); modif used (10); tar and non cd 3 (5, 6)
Inpatient Services medne (4–6); tar and non cd 3 (5–9)
Obstetrics eval (19); modif used (10); tar and non cd 3 (5, 6)
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5. Updated List of Drugs Requiring a SAR for CCS and GHPP

Effective retroactively for dates of service on or after July 1, 2015, Ombitasvir/Paritaprevir/Ritonavir is added to the list of drugs requiring a Service Authorization Request (SAR) for the California Children's Services (CCS) program and the Genetically Handicapped Persons Program (GHPP).

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 (7); genetic (9)
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6. Alert: California Upgrades Prescription Drug Monitoring Program to CURES 2.0

A new DUR Educational Article titled “Alert: California Upgrades Prescription Drug Monitoring Program to CURES 2.0” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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7. March 2016 Medi-Cal Provider Seminar

The next Medi-Cal Provider Seminar is scheduled for March 23, 2016, at the Sacramento Marriott in Rancho Cordova, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

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

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative page, enter the zip code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact your Regional Representative, you 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 page and refer to it often for current seminar information.

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8. National Correct Coding Initiative Quarterly Update for January 2016

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 January 1, 2016.

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

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For more information about MCSS, please visit the MCSS Help page.

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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