Medi-Cal Update

Inpatient Services | January 2018 | Bulletin 520

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1. 2018 CPT-4/HCPCS Annual Update: Policy Updates

The 2018 updates to the Current Procedural Terminology – 4th edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2018 CPT-4/HCPCS 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-4 and HCPCS codes are reflected in the following PDF documents:

The code additions, changes and deletions are effective for dates of service on or after February 1, 2018. Please refer to the 2018 CPT-4 and HCPCS Level II code book for complete descriptions of these codes.

HCPCS codes J7210 and J7211 will be effective for dates of service on or after April 1, 2018.

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

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids audio (9, 10); cal child ser (1–20, 25, 26, 30–32); tax (9–12)
Adult Day Health Centers audio (9, 10)
CHDP Provider Manual chdp trans (1)
Chronic Dialysis Clinics blood (7); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); path bil (8); vaccine (4, 8)
Clinics and Hospitals allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5–7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 30, 32, 35, 36, 41, 42); preg com los (1); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Durable Medical Equipment cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7); tax (9–12)
Family PACT ben fam (23, 25, 30, 41); ben grid (3, 4, 7, 24); drug (2, 7)
General Medicine allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
cal child ser (1–20, 25, 26, 30–32)
Inpatient Services cal child ser (1–20, 25, 26, 30–32); hyst (4); ster (26); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9)
Obstetrics cal child ser (1–20, 25, 26, 30–32); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); ster (26); surg bil mod (7, 8); surg female (2); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Orthotics and Prosthetics cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); tax (9–12)
Pharmacy blood (7); cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); presum (11, 12, 15, 17, 19); tax (9–12)
Psychological Services cal child ser (1–20, 25, 26, 30–32); psychol (2, 4)
Rehabilitation Clinics audio (9, 10); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); respir (6, 7); vaccine (4, 8)
Therapies audio (9, 10); cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7)
Vision Care cal child ser (1–20, 25, 26, 30–32); medi non cpt (2)
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2. CCS Service Code Groupings Update

The following codes will be added to the California Children's Services (CCS) Service Code Groupings (SCGs).

Added Codes:

Effective Date Code SCGs
January 1, 2016 CPT-4 codes 80180, 86352, 86832, 86833, 96150, 96151, 96153, 99485, 99486 02, 03
January 1, 2016 CPT-4 codes 81265, 81267, 81268
HCPCS code G0452
03

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

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 ser (1, 3, 5–9, 11, 12, 14–19, 25, 26, 30, 31)
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3. Diabetes Prevention Program Established for Medi-Cal

Effective July 10, 2017, Senate Bill 97 (Chapter 52, Statutes of 2017), requires the Department of Health Care Services (DHCS) to establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems, consistent with the guidelines provided by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

A core benefit of Medi-Cal's DPP will include 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. Participants who achieve and maintain a minimum weight loss of 5 percent by the conclusion of the 12 month period will also be eligible to receive ongoing maintenance sessions to help them continue healthy lifestyle behaviors. SB 97 also requires that Medi-Cal providers choosing to offer DPP services comply with CDC guidance and obtain CDC recognition in connection with the National DPP.

The benefit will be available to eligible Medi-Cal recipients on January 1, 2019. DHCS is working with its Managed Care Plans, the Department of Public Health, Public Health Advocates and other interested stakeholders to discuss policy implications and potential collaborations. DHCS will begin drafting its policy and submit a CMS State Plan Amendment in 2018. To join the stakeholder list and to submit questions or comments, email DHCSDPP@dhcs.ca.gov.

DHCS is conducting a provider survey to better understand how Medi-Cal providers discuss prediabetes with their patients and to receive any comments or concerns regarding Medi-Cal's DPP benefit. DHCS would appreciate provider's feedback through a short 10-minute survey.

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4. DRG NICU-Surgery Policy Adjustor for State Fiscal Year 2017 – 18 and Eligibility Process for Subsequent State Fiscal Years

Welfare and Institutions Code section 14105.28 authorizes the All Patient Refined – Diagnosis Related Group (DRG) reimbursement methodology as approved by the Centers for Medicare & Medicaid Services (CMS) in pages 17.38 to 17.55 of Attachment 4.19-A of the California State Plan (State Plan). The implementation of DRG payment for inpatient services in a general acute care hospital not reimbursed by certified public expenditures (CPE) includes the functionality of DRG Neonatal Intensive Care Unit (NICU)-Surgery Policy Adjustor that adjusts DRG payment relative weights for neonatal services performed in a California Children's Services (CCS) approved Regional and Community NICU hospital. 

Effective for dates of service on or after August 15, 2017, the process for which a hospital may qualify for the Diagnosis Related Group (DRG) Neonatal Intensive Care Unit (NICU)-Surgery Policy Adjustor is changed. On August 14, 2017, the Department of Health Care Services (DHCS) published a public notice announcing these changes.

Refer to pages 3 and 4 of Appendix 6 to Attachment 4.19-A of the State Plan (Appendix 6) for the DRG NICU-Surgery Policy Adjustor and other DRG payment parameters. Appendix 6 also includes a list of hospitals approved to receive the DRG NICU-Surgery Policy Adjustor and establishes a number of conditions that these hospitals must meet to receive (and continue to receive) the DRG NICU-Surgery Policy Adjustor.

This provider bulletin implements the process changes enacted in CMS' approved SPA 17-032 that defines if and when the DRG NICU Surgery Policy Adjustor will apply to DRG-reimbursed hospitals. This provider bulletin is published under the authority specified in paragraph (2) of subdivision (f) of section 14105.28 of the Welfare and Institutions Code, which provides in part:

“Notwithstanding 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 DHCS published provider bulletins, all-county letters, manuals, or other similar instructions relating to Welfare and Institutions Code section 14105.28. 

How A Hospital Receives Designated NICU Status From CCS

Notice Letter (N.L.) 02-0413, April 12, 2013, sets forth a policy of care for DHCS' CCS-approved NICUs. This includes the types of interventions that NICUs may perform depending on whether or not the NICU has been approved for neonatal surgery. However, N.L. 02-0413 does not make a hospital automatically qualified for the DRG NICU-Surgery Policy Adjustor. An intervention approved under N.L. 02-0413 does not assure payment of the DRG NICU-Surgery Policy Adjustor.

CCS and the DRG Section within DHCS serve distinct roles as they pertain to NICU-Surgery hospitals. CCS will continue to review approved NICU-Surgery hospitals and evaluate new hospital applications to determine whether they meet the requisite standards to be approved to perform neonatal surgery. Upon approval by CCS, the DRG Section will review the information submitted to qualify for the DRG NICU-Surgery Policy Adjustor as a separate request through the Eligibility Process described below.

How A Hospital Qualifies for the DRG NICU-Surgery Policy Adjustor

Refer to the following Eligibility Process changes, enacted in CMS-approved State Plan Amendment (SPA) 17-032, that defines if and when the DRG NICU Surgery Policy Adjustor will apply to the following:

These policies are effective prospectively. Hospitals not currently on the CCS approved NICU surgery hospital list in Appendix 6 may receive the DRG NICU-Surgery Policy Adjustor subject to satisfaction of the requirements set forth in the “NICU Facilities Not Listed In Appendix 6” section below.

NICU Hospitals Listed In Appendix 6 That Are Approved To Receive The DRG NICU-Surgery Policy Adjustor

Appendix 6 sets forth DRG payment parameters, including the DRG NICU-Surgery Policy Adjustor for designated NICU facilities and surgery sites recognized by CCS to perform neonatal surgery. Appendix 6 includes terms and conditions that the listed hospitals must meet in order to receive (and continue to receive) the DRG NICU-Surgery Policy Adjustor.

Hospitals listed under Appendix 6 qualify for the DRG NICU-Surgery Policy Adjustor under the following conditions:

NICU Facilities Not Listed In Appendix 6

Hospitals not listed in Appendix 6 may be permitted to perform certain surgical interventions assigned to the neonate care category upon CCS approval or if the intervention is otherwise authorized in N.L. 02-0413. However, CCS approval to perform an intervention falling into the neonate care category or performing an intervention authorized under N.L. 02-0413 does not authorize payment of the DRG NICU-Surgery Policy Adjustor.

Before being eligible to receive the DRG NICU-Surgery Policy Adjustor, hospitals not listed in Appendix 6 must have completed each of the following steps:

Once the DRG Section has received the completed request, it will make its best effort to review and approve or reject it within 30 calendar days of the date the request is received. The DRG Section will promptly notify the hospital if it anticipates that the review and determination will take more than 30 calendar days or if the request will not be approved.

If the request is approved by the DRG Section, then the DRG Section-approved hospital will receive the DRG NICU-Surgery Policy Adjustor beginning the next state fiscal quarter.

Note:

The list of hospitals in Appendix 6 will be updated periodically.

How A Hospital No Longer Qualifies For The DRG NICU-Surgery Policy Adjustor

If a hospital loses its CCS neonatal surgery approval/status or is otherwise deemed by CCS as not meeting the applicable requirements set forth in the California Children's Services (CCS) Program Approved Hospitals section in the appropriate Part 2 manual, then the hospital is immediately ineligible to receive the DRG NICU-Surgery Policy Adjustor. This policy is effective on the date the neonatal surgery approval/status is lost.

Being listed in Appendix 6 does not guarantee payment of the DRG NICU-Surgery Policy Adjustor. In the event that a hospital remains listed, but has otherwise been deemed to have lost its neonatal surgery approval/status, it will not receive the DRG NICU-Surgery Policy Adjustor.

For further information or questions regarding State Fiscal Year 2017-18 DRG NICU-Surgery Policy Adjustor as well as the Eligibility Process, contact DHCS' DRG Section at drg@dhcs.ca.gov.

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5. Update: Online PDF RAD and Medi-Cal Financial Summary

In early 2018 providers will be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions tab.

Note:

To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

Benefits of PDF RAD
There will be many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments will be made via PDF RADS. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for PDF RAD updates.

835 Transactions
Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246). The form is located on the Forms page of the Medi-Cal website. The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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6. National Correct Coding Initiative Quarterly Update for January 2018

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, 2018.

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

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7. February 2018 Medi-Cal Provider Seminar

The next Medi-Cal provider seminar is scheduled for February 13 – 14, 2018, at the Ontario Airport Hotel & Conference Center in Ontario, 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 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 and request by January 30, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After January 30, 2018, 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 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 educational information, such as the annual provider seminar and webinar schedule, provider training workbooks, online tutorials, recorded webinars and additional curriculum on the MLP.

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