Medi-Cal Update

Inpatient Services | June 2016 | Bulletin 501

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1. Payment Error Rate Measurement Review for Fiscal Year 2016

The Department of Health Care Services (DHCS) wishes to notify all California Medi-Cal providers of the Payment Error Rate Measurement (PERM) review that is being conducted in California by the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to measure improper payments in the Medicaid program and the Children’s Health Insurance Program (CHIP), as required by the Improper Payments Information Act (IPIA).

The error rates are based on reviews of the fee-for-service, Managed Care and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note that the error rate is not a fraud rate, but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.

Approximately 383 Medi-Cal claims will be selected from each quarter between October 1, 2015, and September 30, 2016. Providers whose claims have been selected for review will receive requests from CNI Advantage, the review contractor (RC), for copies of medical records.

Providers will also need to send a duplicate copy of the medical records requested by the RC to DHCS. DHCS is taking this proactive step in order to review the submitted documentation and determine if further information is needed to support the claim. In cases where medical records have not been submitted or further information is needed, providers will be contacted by a DHCS representative to help facilitate obtaining copies of this important documentation.

DHCS is urging all providers to comply with requests for medical records from the RC and DHCS. Failure to comply with the request from the RC will result in an error being counted against California, and DHCS will be required to recover the claim payment amount from providers. Your cooperation will help ensure that the payment measurement rate is accurate and that California retains its much needed federal match funding for the Medi-Cal Program.

CMS will host four PERM provider education sessions which will allow Medicaid and CHIP providers to enhance their understanding of provider responsibilities during the PERM review cycle. Participants will have the opportunity to ask questions live through the conference lines via the webinar and through the dedicated PERM provider email address at PERMProviders@cms.hhs.gov.

Education sessions will be held on the following schedule and can be accessed using the information listed below:

Tuesday, June 21, 2016, noon to 1 p.m.

Wednesday June 29, 2016, noon to 1 p.m.

Tuesday, July 19, 2016, noon to 1 p.m.

Wednesday, July 27, 2016, noon to 1 p.m.

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2. Updated Policy for Pregnancy-Related Services

Effective for dates of service on or after July 1, 2016, pregnancy-related policy is updated in the provider manual. These policy updates include clarification to full-scope and limited-scope Medi-Cal eligibility and reimbursement for pregnant individuals. Licensed Midwives (LM) are added to the Comprehensive Perinatal Services Program (CPSP) list of Contract Service Providers (CSP). Billing policy for local code Z1038 (postpartum visit) is updated with the following frequency limitation:

Providers may bill more than one postpartum visit in six months by documenting the postpartum complication in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim form or in the attachment for reimbursement.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals preg com (2, 5); preg early (1, 2, 4); preg ex ub (1); preg glo (1, 3, 4); preg per (1, 2); preg per cd (1); preg post (3 – 5); psych (1); spec (1)
General Medicine eval (2, 5); preg com (2, 5); preg early (1, 2, 4); preg ex cms (1); preg glo (1, 3, 4); preg per (1, 2); preg per cd (1); preg post (3 – 5); psych (1); spec (1)
Home Health Agencies/Home and Community-Based Services preg post (3 – 5)
Inpatient Services inp ment (1); preg post (3 – 5)
Obstetrics eval (2, 5); preg com (2, 5); preg early (1, 2, 4); preg ex cms (1); preg glo (1, 3, 4); preg per (1, 2); preg per cd (1); preg post (3 – 5)
Psychological Services psychol (1); psychol ex (1); spec (1)
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3. Update to CPT-4 Codes for Allergen Immunotherapy Services

Effective for dates of service on or after July 1, 2016, CPT-4 codes 95144 (professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vial(s)) and 95170 (…whole body extract of biting insect or other arthropod) are Medi-Cal benefits.

HCPCS codes X7708 (standard antigens sets) and X7710 (hymenoptera venom antigen vials) have been terminated. Code 95144 replaces local code X7708. Code 95170 replaces local code X7710.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
inject drug a-d (5)
Clinics and Hospitals
General Medicine
allergy (2, 3); inject drug a-d (5); non ph (8, 20); tar and non cd9 (4)
Inpatient Services tar and non cd9 (4)
Obstetrics inject drug a-d (5); non ph (8, 20); tar and non cd9 (4)
Rehabilitation Clinics inject drug a-d (5); non ph (8, 20)
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4. Update to TAR Requirements for Molecular Pathology CPT-4 Codes

Effective for dates of service on or after June 1, 2016, CPT-4 code 81161 (DMD [dystrophin] deletion analysis, and duplication analysis, if performed) is a Medi-Cal benefit. Code 81161 is limited to once-in-a-lifetime frequency for any provider and it must be billed with ICD-10-CM diagnosis code G71.0 (muscular dystrophy).

Also effective for dates of service on or after June 1, 2016, DMD (dystrophin), full gene sequence is added for CPT-4 code 81408 (molecular pathology procedure, Level 9). The following are the Treatment Authorization Request (TAR) criteria:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
once (6); path molec (2, 29); tar and non cd8 (2)
Inpatient Services tar and non cd8 (2)
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5. Updated ICD-10-CM and TAR Requirements for Lynch Syndrome Genetic Testing

Effective for dates of service on or after July 1, 2016, several new ICD-10-CM diagnosis codes are available for use on claims for Lynch syndrome genetic testing.

In addition, Treatment Authorization Request (TAR) requirements have been updated for genetic testing codes as follows:

CPT-4 Code Description TAR Requirement
81294 MLH1 gene analysis; duplication/deletion variants TAR no longer required
81297 MSH2 gene analysis; duplication/deletion variants
81300 MSH6 gene analysis; duplication/deletion variants
81319 PMS2 gene analysis; duplication/deletion variants
81403 Molecular pathology procedure, Level 4 TAR criteria updated

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (9 – 12, 19, 32); tar and non cd8 (2)
Inpatient Services tar and non cd8 (2)
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6. Financial Responsibility Agreement Required to Receive HQAF Program Payments

Following a hospital change of ownership (CHOW), the new owner of the hospital must agree to be financially responsible to the Department of Health Care Services (DHCS) for the hospital’s known and unknown outstanding monetary obligations to the Medi-Cal program to receive Hospital Quality Assurance Fee (HQAF) program payments and avoid being considered a “new hospital.”

DHCS must receive a complete and correct Financial Responsibility Agreement from the new owner within 30 calendar days from the date of issue of the new owner’s Medi-Cal certification. A hospital continues to be obligated to pay HQAF program fees from the CHOW date unless it is determined to be a “new hospital.”

For more information refer to the Non-Assumption New Hospital Provider PDF. Providers may also visit the Hospital Quality Assurance Fee Program page of the DHCS website.

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7. Provider Manual Survey Now Available

Department of Health Care Services (DHCS) offers the Provider Manual on the Medi-Cal website in Microsoft Word format and as a ZIP (compressed file). The website also contains links to free software to view these file formats.

DHCS is exploring modernizing the Medi-Cal, Child Health and Disability Prevention (CHDP) and Family Planning, Access, Care and Treatment (Family PACT) provider manuals to reflect the shift to mobile computing.

This Provider Manual Survey will collect provider feedback on this modernization effort. Responses will help DHCS assess provider concerns about moving toward a more mobile-friendly platform. While participation is not required, DHCS encourages all providers to take the survey. All answered surveys will be kept confidential and anonymous.

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8. ICD-10 Information Added to Share of Cost (SOC) Tutorial Examples

The form examples in the “Share of Cost (SOC) Tutorial” are updated to be congruent with ICD-10 policy. The tutorial is accessible from the Provider Training page of the Medi-Cal Learning Portal (MLP).

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9. ICD-10 Information Added to Crossover Claims Tutorial Examples

The form examples in the “Crossover Claims Tutorial” are updated to be congruent with ICD-10 policy. The tutorial is accessible from the Provider Training page of the Medi-Cal Learning Portal (MLP).

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10. July 2016 Medi-Cal Provider Seminar

The next Medi-Cal Provider Seminar is scheduled for July 26 – 27, 2016, at the Ventura Beach Marriott in Ventura, 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 must register by July 12, 2016, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 12, 2016, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks page of the Medi-Cal website.

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 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 page and refer to it often for current seminar information.

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

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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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