Medi-Cal Update

Inpatient Services | May 2017 | Bulletin 512

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2. Providers to Report PPCs Using DHCS Secure Online Portal

Effective June 1, 2017, the Department of Health Care Services (DHCS) will no longer accept paper forms for reporting provider-preventable conditions (PPCs). DHCS began accepting online reporting of PPCs for Medi-Cal on April 3, 2017. The development of secure online submission is in response to provider requests to make PPC reporting easier. This new online process replaces the paper Medi-Cal Provider-Preventable Conditions (PPC) Reporting Form (DHCS 7107). The secure online reporting portal is available on the Instructions for online reporting of PPCs Web page of the DHCS website.

Providers must report health care-acquired conditions (HCACs) when they occur in an acute hospital inpatient setting, and report other provider-preventable conditions (OPPCs) when they occur in any health care setting, according to state law in Welfare and Institutions Code (W&I Code), Section 14131.11, as well as the Code of Federal Regulations (CFR) Title 42, Sections 434, 447 and 438. Providers must report PPCs for any Medi-Cal recipient when any PPC occurs that did not exist prior to the provider initiating treatment, even if the provider will not seek Medi-Cal reimbursement to treat the PPC.

More information about PPC reporting requirements, PPC definitions and mandatory payment adjustments is available on the Medi-Cal Guidance on Reporting Provider-Preventable Conditions Web page of the DHCS website. Providers may email questions about the new PPC process to PPCHCAC@dhcs.ca.gov.

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3. 2017 ICD-10-CM Diagnosis Code Annual Update

A previously published NewsFlash article titled “Additional Information: 2017 ICD-10-CM Diagnosis Code Update” notified providers that, with the 2017 annual ICD-10-CM update, a number of diagnosis codes have been expanded for greater detail. The Medi-Cal Provider Manuals and the Family PACT Policies, Procedures and Billing Instructions manual are now updated to reflect these expansions. Deactivated codes have been removed.

Providers should use the new, expanded codes when billing for dates of service on or after October 1, 2016.

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Medical Transportation
Orthotics and Prosthetics
Therapies
cms comp (14)
Chronic Dialysis Clinics inject drug i-m (10); path chem (2–4, 6, 8–10)
Clinics and Hospitals chemo drug p-z (17); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Durable Medical Equipment cms comp (14); incont (8)
Family PACT ben fam rel (8, 10, 13); ben grid (13–15); lab (12–14, 26, 28)
General Medicine chemo drug p-z (17); cms comp (14); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Inpatient Services minor (3)
Long Term Care incont (8)
Obstetrics cms comp (14); ev woman (16, 17); inject drug i-m (10); minor (3); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); radi dia ult (1); radi nuc (1)
Pharmacy cms comp (14); incont (8); inject drug i-m (10)
Psychological Services cms comp (14); spec (2)
Rehabilitation Clinics inject drug i-m (10)
Vision Care minor (3); pro serv cd (2–4, 6, 7)
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4. Updated Drugs and Nutritional Products List Requiring SAR for CCS and GHPP

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

Effective retroactively for dates of service on or after June 1, 2016, Sofosbuvir/Velpatasvir is added to the pharmacy list of drugs and nutritional products requiring a separate SAR for CCS and 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 (8); genetic (9)
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5. Two Preventative Medical Evaluations Added as Benefits

Effective for dates of service on or after June 1, 2017, CPT-4 codes 99385 (initial comprehensive preventative medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions and the ordering of laboratory/diagnostic procedures, new patient; 18 – 39 years) and 99395 (periodic comprehensive preventative medicine reevaluation and management of an individual … established patient; 18 – 39 years) are added as Medi-Cal benefits.

Codes 99385 and 99395 are Medi-Cal benefits for recipients ages 18 – 21 with no diagnosis or place of service restrictions and a frequency limitation of once per year. The only valid modifiers for this code are as follows:

Modifier National Description
99 Multiple modifiers
SA Nurse practitioner rendering service in collaboration with a physician
SB Nurse midwife
U7 Medicaid level of care 7, as defined by each state

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (15); non ph (8); tar and non cd 9 (8, 21)
Inpatient Services tar and non cd 9 (8)
Rehabilitation Clinics non ph (8, 21)
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6. 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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7. Improving the Quality of Care: Overutilization of Proton Pump Inhibitors

A new DUR Educational Article titled “Improving the Quality of Care: Overutilization of Proton Pump Inhibitors” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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8. Alert: Medi-Cal Expands Access to Adult Immunizations in Pharmacies

A new DUR Educational Article titled “Alert: Medi-Cal Expands Access to Adult Immunizations in Pharmacies” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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9. June 2017 Medi-Cal Provider Training Webinars

Beginning June 1, 2017, and continuing throughout the month of June, 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 and Education page of the Medi-Cal website.

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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