Medi-Cal Update

Long Term Care | December 2019 | Bulletin 514

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1. October 2019 HCPCS Quarterly Update: Policy Updates

The October 2019 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the Quarter 4 HCPCS Policy (Medi-Cal) PDF. Only those codes representing Medi-Cal benefits effective October 1, 2018, are included in the list of updates.

Please refer to the 2018 HCPCS Level II code book for complete descriptions of these codes.

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

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 32, 33, 41, 42); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12)
Clinics and Hospitals
General Medicine
chemo drug a-d (14, 15, 21); chemo drug e-o (2, 3, 17–19, 21–24); chemo drug p-z (15, 25, 26); inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25); ophthal (15–17, 19–22); surg integ (4, 5, 9)
Obstetrics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25)
Rehabilitation Clinics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25)
Pharmacy inject an over (1); inject cd list (2–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 32, 33, 41, 42); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 9, 13, 17, 22–24)
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2. 2020 CPT Annual Update

The 2020 updates to the Current Procedural Terminology (CPT) codes are available in the 2020 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for dates of service on or after January 1, 2020. Please refer to the 2020 CPT code book for complete descriptions of these codes.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
cardio (9, 10); chemo an over (1); epsdt chdp school (5); eval (31); inject an over (1); inject cd list (9); medne neu (3, 4, 8); medne non (1); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); once (7); ophthal (2, 4, 10); ophthal cd (7); path drug (4); path micro (7); path molec (2, 64, 65); presum bill (10, 11); radi nuc (3, 4); surg bil mod (7); surg cardio (9); surg eye (1); tar and non cd1 (4, 6); tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10); vaccine (4)
Obstetrics eval (31); inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); once (7); path drug (4); path micro (7); path molec (2, 64, 65); presum bill (10, 11); radi nuc (3, 4); surg bil mod (7); tar and non cd1 (4, 6); tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10); vaccine (4)
Rehabilitation Clinics inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); vaccine (4)
Chronic Dialysis Clinics inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); vaccine (4)
Inpatient tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10)
Local Educational Agencies loc ed bil cd (8, 10, 11, 14, 22); loc ed serv nurs (5); loc ed serv physican (5); loc ed serv psych (7); modif app (12, 13)
Vision Care modif app (12, 13); modif used vc (2); pro serv (4, 11, 17, 19, 20); pro serv cd (7, 8); rates max optom (2)
Pharmacy inject an over (1); inject cd list (9); presum bill (10, 11)
AIDS Waiver Program modif (3); modif app (12, 13)
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3. 2019 – 2020 Distinct-Part Pediatric Subacute Reimbursement Rates Established

Effective for dates of service on or after August 1, 2019, the reimbursement rates for Distinct-Part Pediatric Subacute (DP/PSA) facilities are established.

Facilities should begin using these rates to bill for services. Facilities do not need to rebill to adjust their payments. Claims with dates of service on or after August 1, 2019, will automatically be adjusted by the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) for proper claims payment. Letters regarding the rate updates will be sent to DP/PSA facilities. Additionally, the 2019 – 2020 reimbursement rates are posted on the Distinct Part Pediatric Subacute (DP/PSA) and Freestanding Pediatric Subacute (FS/PSA) Facilities page on the Department of Health Care Services (DHCS) website.

The 2019 – 2020 DP/PSA reimbursement rates are based on a model developed from comparable peer group cost information, in addition to the cost of new state or federal mandates (add-ons). The calculated ventilator-dependent rate is $1,161.35 and the non-ventilator rate is $1,064.07.

2019 – 2020 DP/PSA Reimbursement Rates
83 84 85 86 87/89 88/90
$72.15 $67.27 $1,161.35 $1,064.07 $1,153.00 $1,055.72

The 2019 – 2020 add-ons include the following:

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

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (8, 9)
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4. Updated Reimbursement Rates for Distinct Part Adult Subacute Facilities

Effective for dates of service on or after August 1, 2019, the California Department of Health Care Services (DHCS) has updated the 2019 – 2020 Medi-Cal reimbursement rates for Distinct-Part Adult Subacute (DP/ASA) facilities.

Providers do not need to rebill to adjust their payments; California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) will process any retroactive rate adjustments for claims paid at the old rate for services provided on or after August 1, 2019.

For billing or payment questions, providers should call the CA-MMIS FI Telephone Service Center at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday.

DHCS will notify providers of their DP/ASA facility specific rates in a separate letter. In the meantime, providers may find their rates posted on the Subacute Care Facilities page on the DHCS website.

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

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (7)
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5. 2019 – 2020 Intermediate Care Facility Reimbursement Rates Update

Effective for dates of service on or after August 1, 2019, the 2019 – 2020 reimbursement rates for Intermediate Care Facilities for the Developmentally Disabled (ICF/DDs), Intermediate Care Facilities for the Developmentally Disabled/Habilitative (ICF/DD-Hs) and Intermediate Care Facilities for the Developmentally Disabled/Nursing (ICF/DD-Ns) are updated.

Pursuant to State Plan Amendment (SPA) 16-012 and Welfare and Institutions Code (W&I Code), Section 14105.075, the Department of Health Care Services (DHCS) is authorized to reimburse facilities at the applicable 2008 – 2009 65th percentile per diem rate established for the facility’s respective peer group, increased by 3.7 percent. The reimbursement rate includes the projected cost of complying with any state or federal mandates to the extent applicable to the reimbursement methodology associated with the type of facility.

DHCS is providing a facility-specific reimbursement by way of an add-on to the Medi-Cal reimbursement rate for the additional cost of health care coverage solely due to Employer Shared Responsibility requirements in the Patient Protection and Affordable Care Act (ACA) embodied in Section 4980H of the Internal Revenue Code (IRC). Effective August 1, 2019, the rates will include the additional facility-specific add-on related to the ACA Employer Shared Responsibility mandate and the ACA Internal Revenue Service (IRS) Employer Reporting mandate, only for the facilities that submitted a certification form. Providers should note that individual rate letters will be mailed to the providers that submitted a certification form, since the add-ons are facility specific.

DHCS is providing an additional supplemental payment, effective August 1, 2019. The Centers for Medicare & Medicaid Services (CMS) approved SPA 19-0022 to extend the ICF/DD Proposition 56 supplemental payment and provide an additional time-limited per diem amount for the below peer groups, through December 31, 2021.

Facility Peer Group Long Term Care Accommodation Code (Regular Services) Bed Hold Accommodation Code Supplemental Payment Per Diem
ICF/DD (1 – 59 beds) 41 43 $15.47
ICF/DD (60+ beds) 41 43 0
ICF/DD-H (4 – 6 beds) 61 63 10.75
ICF/DD-H (7 – 15 beds) 65 68 0
ICF/DD-N (4 – 6 beds) 62 64 12.47
ICF/DD-N (7 – 15 beds) 66 69 22.30

Note:

Facilities in peer groups in which the unfrozen 2017 – 2018 65th percentile rate is lower than the current reimbursement rate will not receive the supplemental payment.

The California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) will provide the supplemental payment per diem amounts to the respective peer groups in addition to the regular reimbursement rates, for every claim that is billed for dates of service from August 1, 2019, through July 31, 2020. Providers should bill using the new rates for dates of service on or after August 1, 2019.

Providers do not need to rebill to adjust their payments; the CA-MMIS FI will process any retroactive rate adjustments for claims paid at the old rate. If providers have any questions regarding claims and payments, they may contact the Telephone Service Center at 1-800-541-5555.

The new rates, ACA add-ons, supplemental payments and other information related to ICF/DDs, ICF/DD-Hs and ICF/DD-Ns are available on the Intermediate Care Facilities page of the DHCS website.

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
Long Term Care rate facil diem (5)
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6. Long Term Care Facility Rate Change for Nursing Facilities Level A

Effective for dates of service on or after August 1, 2019, reimbursement rates for Long Term Care Nursing Facilities Level A (NF-As) are updated to include the following mandated add-ons:

NF-A Add-Ons 2019 – 2020 Rate Year
Minimum Data Set (MDS) 3.0 $0.51
Vaccine $0.25
Std Adm Agreement $0.02
Elder Justice Act $0.01
Patient Protection and Affordable Care Act (ACA) Reinsurance Fee & Patient-Centered Outcomes Research Institute (PCORI) $0.04
HIPAA Electronic Funds Transfer (EFT) and Remittance Advice (RA) $0.03
ACA Compliance Program $0.66
Minimum Wage (July 2014) $1.71
Minimum Wage (January 2016) $2.43
ACA Reporting $0.43
Sick Leave (July 2015) $1.72
Minimum Wage (January 2017 Senate Bill 3) $0.17
Minimum Wage (January 2018 SB 3) $1.36
Minimum Wage (January 2019 SB 3) $0.55
Minimum Wage (January 2020 SB 3) $0.50
Standard Participation $0.01
Infection Control $1.31
LGBT $0.01
2017 – 2018 Payroll-Based Journal $0.13
Total 2019 – 2020 Add-Ons $11.85

Assembly Bill 97 added Sections 14105.07 and 14105.192 of the Welfare and Institutions Code (W&I Code) authorizing the Department of Health Care Services (DHCS) to reduce Medi-Cal provider payments up to 10 percent, originally effective for dates of service on or after June 1, 2011. In addition, AB 97 requires that the Medi-Cal reimbursement rates for specified provider classes shall not exceed the reimbursement rates applicable to those provider classes in the 2008 – 2009 rate year, as described in subdivision (f) of Section 14105.191 of the W&I Code.

Effective August 2, 2003, NF-A per diem rates for facilities with a licensed bed capacity of 99 or fewer stopped utilizing bed size to establish rates. NF-A rates are set solely by geographical location. NF-A per diem rates for facilities with a licensed bed capacity of 100 or more, that received a rate of $89.54, effective August 1, 2002, were required to continue to receive this rate until such time their prospective county rate reaches this level.

Providers should bill using the new rates for dates of service on or after August 1, 2019. Providers do not need to rebill to adjust their payments. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

The rates are posted on the Freestanding Nursing Facilities, Level A (NF-A) page of the DHCS website.

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

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (1)
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7. 2019 – 2020 Distinct-Part Nursing Facilities Level B Reimbursement Rates

Effective for dates of service on or after August 1, 2019, the 2019 – 2020 reimbursement rates for Distinct-Part Nursing Facilities Level B (DP/NF-B) are established.

Providers should bill using the new rates for dates of service on or after August 1, 2019. Providers do not need to rebill to adjust their payments; the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) will process any retroactive rate adjustments for claims paid at the old rate.

Providers will be notified of their DP/NF-B facility-specific rates via letter. Additionally, the rates are posted of the Distinct Part Nursing Facilities, Level B (DP/NF-B) page on the Department of Health Care Services (DHCS) website.

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

For billing or payment questions, providers may call the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday.

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

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (2)
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8. Institutions for Mental Diseases Reimbursement Rates Update

Effective for dates of service on or after July 1, 2019, rates are increased by 3.5 percent for Freestanding Skilled Nursing Facilities Level-B (FS/NF-Bs) designated as Institutions for Mental Diseases (IMD). These facilities are exempt from the California Assembly Bill (AB) 1629 (Statutes of 2004, Chapter 875) facility-specific rate methodology and the Quality Assurance Fee program. AB 1054, (Statutes of 2013, Chapter 303) mandates an annual increase of 3.5 percent when specified conditions are met, beginning July 1, 2014.

The updated rates are as follows:

TOTAL BEDS 1 – 59 TOTAL BEDS 60 PLUS
Accommodation Code S.F.* Bay Area Counties Los Angeles County All Other Counties S.F.* Bay Area Counties Los Angeles County All Other Counties
01 $ 220.83 $ 178.32 $ 191.87 $ 232.10 $ 178.56 $ 199.22
02   212.48   169.97   183.52   223.75   170.21   190.87
03   212.48   169.97   183.52   223.75   170.21   190.87
11   226.55   184.04   197.59   237.82   184.28   204.94
12   218.20   175.69   189.24   229.47   175.93   196.59

*San Francisco Bay Area counties include Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara and Sonoma.

The rates shown above for accommodation codes 11 and 12 include the Special Treatment Program (STP) supplement of $5.72 per day.

Also effective for dates of service on or after July 1, 2019, the rate reduction for IMD leave of absence and bed hold for acute hospitalization is updated to $8.35 per diem.

For more information, see California AB 360 (Statutes of 2005, Chapter 508) and AB 1054 (Statutes of 2013, Chapter 303) in the Rates: Facilities section in the Long Term Care provider manual.

An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims. No action is required of providers.

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

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (4)
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9. Continuity of Care at Skilled Nursing and Intermediate Care Facilities

A previously published NewsFlash article, titled “Clarification of Skilled Nursing and Intermediate Care Facilities Services” clarified skilled nursing and intermediate care facilities services. This article is to provide additional information about continuity of care at skilled nursing and intermediate care facilities.

Code of Federal Regulations (CFR), Title 42, Section 440.155(a)(1) defines nursing facility services as those provided in a facility that “fully meets the requirements for a State license to provide, on a regular basis, health-related services to individuals who do not require hospital care, but whose mental or physical condition requires services that – (i) are above the level of room and board; and (ii) can be made available only through institutional facilities.”

Federal law allows continuity of care protections for individuals to receive medically necessary intermediate care services at the NF-B where they are receiving medically necessary skilled nursing services. If a Medi-Cal recipient needs intermediate care services, but the NF-B facility is not licensed to provide intermediate care, the facility can arrange for transfer to a facility that provides intermediate care services if the recipient is ready for transfer and there are beds available in that facility. While the recipient is awaiting transfer, the NF-B shall continue to provide medically necessary services to the recipient until another facility is available.

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

Provider Manual(s) Page(s) Updated
Long Term Care patient ltc (1); tar comp ltc (1, 5, 6)
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10. Podiatry Services Restored as Medi-Cal Covered Benefits

Effective for dates of service on or after January 1, 2020, podiatry services previously eliminated as part of the optional benefits exclusion are reinstated as full Medi-Cal benefits.

In addition, Welfare and Institutions (W&I) code, Section 14133.07 was recently amended to remove two visit limit and to remove the same TAR requirements for services by podiatrists as for physicians and surgeons.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Chiropractic
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
opt ben exc (1–4, 6, 7, 13)
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11. Audiology and Speech Therapy Services Restored as Medi-Cal Benefits

Effective for dates of service on or after January 1, 2020, audiology and speech therapy services previously eliminated as part of the optional benefits exclusion are reinstated as full Medi-Cal benefits.

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

Provider Manual(s) Page(s) Updated
Chiropractic
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Pharmacy
Psychological Services
Vision Care
opt ben exc (1–4, 6–8, 13, 16–18)
Audiology and Hearing Aids
Adult Day Health Care Centers
Rehabilitation Clinics
Therapies
audio (1, 3, 6); opt ben exc (1–4, 6–8, 13, 16–18); speech (1)
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12. National Correct Coding Initiative Quarterly Update for January 2020

The Centers for Medicare & Medicaid Services (CMS) are scheduled to routinely release the quarterly National Correct Coding Initiative (NCCI) in Medicaid payment policy updates. These mandatory national edits will be incorporated into the Medi-Cal claims processing system and will be effective for dates of service on or after January 1, 2020.

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

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13. Updates to Incontinence Creams and Washes

Effective for dates of service on or after January 1, 2020, incontinence creams and washes require authorization and are no longer restricted to recipients under 21 years of age. Products on the List of Contracted Incontinence Creams and Washes are reimbursable with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) for recipients 5 years of age or older. The List of Incontinence Medical Supply Billing Codes is also updated to reflect this change. The Optional Benefits Exclusion section of the appropriate Part 2 manual will be updated in a future Medi-Cal Update.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (1, 2, 4–7, 9, 12)
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15. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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