Medi-Cal Update

Inpatient Services | March 2017 | Bulletin 510

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1. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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2. Update: DHCS Fiscal Intermediary Name Change

Effective immediately, providers may notice that the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) for the Medi-Cal program, formerly Xerox State Healthcare, LLC (Xerox), is operating under a new company name, “Conduent.” Providers may also see the Conduent logo on some items.

Operations and interactions with providers are not impacted by this FI name change.

Providers may see this name change in items such as:

  • NewsFlash articles and Medi-Cal Update bulletins
  • Medi-Cal website (www.medi-cal.ca.gov)
  • Forms and User Guides
  • Provider Manuals
  • Medi-Cal Learning Portal (MLP)
  • Presentations at Provider Training Seminars
  • Provider Letters, such as Erroneous Payment Corrections (EPCs)
  • Additional hard copy correspondence
  • Emails with an “@conduent.com” address rather than an “@xerox.com” address
  • References to the Conduent name when researching mailing addresses or published telephone numbers
Conduent logo

There are no changes in the telephone numbers used by providers, including the Telephone Service Center (TSC) number (1-800-541-5555), as a result of this name change. The mailing addresses used by providers to conduct business with DHCS and the FI will remain the same.

Medi-Cal providers are strongly encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles, and System Status Alerts. Providers may sign up for MCSS by visiting http://www.medi-cal.ca.gov and completing the MCSS Subscriber Form. For more information about Conduent, visit https://www.conduent.com.

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3. DRG Billing and Reimbursement Update for AIIR Services

For admissions beginning on or after July 1, 2013, the Department of Health Care Services (DHCS) has reimbursed fee-for-service (FFS) acute inpatient intensive rehabilitation (AIIR) services rendered by diagnosis-related group (DRG) hospitals to Medi-Cal recipients through a hospital-specific, all-inclusive per diem rate in accordance with the APR-DRG Reimbursement Implementation.

For the purposes of FFS reimbursement to DRG hospitals, “Rehabilitation Services” are defined as AIIR services in accordance with Welfare and Institutions Code (W&I Code), Sections 14064 and 14132.8. Rehabilitation services are identified by the presence of revenue codes 118, 128, 138 or 158 in the Revenue Code field (Box 42) of the UB-04 form on one or more service lines on the claim and include the ancillary services provided during the stay in accordance with W&I Code, Sections 14064 and 14132.8.

To receive accurate reimbursement for rehabilitation services, DRG hospitals should indicate in the Total Charges field (Box 47) at a minimum the all-inclusive, hospital-specific per diem rates in the HCPCS/Rate field (Box 44) multiplied by the number of authorized days in the Service Units field (Box 46) for the service period on the required Treatment Authorization Request or Service Authorization Request. If the charges reflected for the rehabilitation services on the claim are lesser than the all-inclusive, hospital-specific calculation, it will pay at the lesser of the two.

The all-inclusive, hospital-specific per diem rate for rehabilitation services is available on the Diagnosis Related Group Hospital Inpatient Payment Methodology Web page of the DHCS website.

Retroactive Application of Billing at the All-Inclusive Per Diem for Rehabilitation Services
If the reimbursement for rehabilitation services was less than the calculated amount based on the all-inclusive, hospital-specific per diem rates, resubmit the claim through a Claims Inquiry Form (CIF) and appeal for claim reimbursement reprocessing by taking the following steps:

  1. Void claims through a CIF, mark the “Overpayment” box and include the statement “Please void claim, not an overpayment but an acute inpatient intensive rehabilitation service correction to increase payment” in the remarks area. (Please note, in order to waive timeliness guidelines providers must check the “Overpayment” box on the CIF, not the “Underpayment” box.)

  2. Once the voided claim appears on a Remittance Advice Details (RAD), resubmit the corrected claim with an Appeal Form and request reprocessing. Attach the RAD of the voided claim to show timeliness filing. The claim must be resubmitted within 90 days from the RAD date.

All corrected claims must be submitted by March 31, 2017.

For further information or questions regarding AIIR service reimbursement, contact DHCS at drg@dhcs.ca.gov.

This provider bulletin is published under the authority specified in paragraph (2) of subdivision (f) of section 14105.28 of the W&I Code, which provides in part:

“[N]otwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, or any other provision of law, the department may implement and administer this section by means of provider bulletins, all-county letters, manuals, or other similar instructions, without taking regulatory action.”

This provider bulletin governs should there be a conflict between this provider bulletin and any previous Department published provider bulletins relating to W&I Code section 14105.28.

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4. Extended Deadline of the Streamlined Procedure for ACA-Related Appeals

The filing period for submission of Patient Protection and Affordable Care Act-related (ACA) appeals is extended from June 30, 2016, to December 31, 2017. The deadline has been extended to assist providers in completing all their ACA-related appeals.

The Streamlined Procedure for ACA-Related Appeals published February 23, 2016, details the submission of appeals regarding ACA payments for Medi-Cal services. Providers should closely follow the article's instructions in all regards except for the filing deadline.

Providers with questions may call the Telephone Service Center at 1-800-541-5555.

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5. Policy Update: ECMO/ECLS Age Groups

Effective retroactively for dates of service on or after January 1, 2015, Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Life Support (ECLS) procedures will cover all ECMO/ECLS codes for all age groups (0 – 5 years of age and 6 – 99 years of age).

The following CPT-4 codes are Medi-Cal benefits for ECMO/ECLS procedures that will cover all age groups (0 – 5 years of age and 6 – 99 years of age):

CPT-4 Code Description
33946 Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947 initiation, veno-arterial
33948 daily management, each day, veno-venous
33949 daily management, each day, veno-arterial
33951 insertion of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33953 insertion of peripheral cannula(e), open, birth through 5 years of age
33955 insertion of peripheral cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33957 reposition of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33959 reposition of peripheral 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 cannula(e), percutaneous, birth through 5 years of age
33969 removal of peripheral 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

In order to perform ECMO/ECLS for infants, the institution must be a California Children’s Services (CCS) approved Neonatal Intensive Care Unit (NICU) as both a regional NICU and an ECMO center. The institution must also be capable of providing inhaled nitric oxide services for neonates for children.

In order to perform ECMO for recipients awaiting lung transplantation, the institution must be a Medi-Cal approved Center of Excellence for lung transplantation and have performed ECMOs on adults for a minimum of three years and performed an average of five ECMOs per year.

Daily overall management of the recipient may be separately reported using the relevant hospital inpatient services or critical care evaluation and management codes (99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 and 99480) and may be reimbursed to any provider, same recipient and same date of service.

Services must be submitted on the claim with all revenue/sick baby codes applicable to the entire stay. An infant claim must be submitted for services rendered to the baby only. Care for the mother is billed separately.

The following are revenue codes for ECMO services provided to newborns, infants and children, and adults:

Revenue Code Description
174 Nursery, Newborn; Level IV (newborn 0-28 days)
202 Intensive Care, Medical (adults)
203 Intensive Care, Pediatric (infants and children)

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

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Rehabilitation Clinics
modif used (11)
Clinics and Hospitals
General Medicine
medne (4–7); modif used (11); tar and non cd3 (5, 6)
Inpatient Services medne (4–7); tar and non cd3 (5, 6)
Obstetrics modif used (11); tar and non cd3 (5, 6)
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6. Improving the Quality of Care: Risks Associated with Use of Fluoroquinolones

A new DUR Educational Article titled “Improving the Quality of Care: Risks Associated with Use of Fluoroquinolones” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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7. April 2017 Medi-Cal Provider Seminar

The next Medi-Cal seminar is scheduled for April 25 – 26, 2017, at the Long Beach Marriott in Long Beach, 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 Conduent, the Fiscal Intermediary 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 April 11, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 11, 2017, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks Web 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 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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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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