Medi-Cal Update

Medical Transportation | April 2015 | Bulletin 475

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1. Medical Transportation Code Conversion Transition Period Established

The March 2015 Medi-Cal Update announced the Medical Transportation Code Conversion as effective for dates of service on or after April 1, 2015.

However, a transition period has been established. Providers may continue to use HCPCS Level III local modifier Z1 and local codes for dates of service beyond April 1, 2015 for claim billing, Treatment Authorization Requests and Service Authorization Requests. Providers are not required, but encouraged, to transition to HCPCS Level II national HIPAA compliant codes as early as April 1, 2015.

A cutoff date for the use of HCPCS Level III local modifier Z1 and local codes will be announced in a future Medi-Cal Update. Providers will be notified at least 90 days prior to the cutoff date.

In collaboration with medical transportation representatives, the Department of Health Care Services (DHCS) is revising the transition approach for the Medical Transportation Code Conversion. During this transition period, providers should continue to monitor the Medi-Cal website for additional information.

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2. Upcoming Changes: HIPAA Code Conversion for Local Modifier ZS

Effective July 1, 2015, the Department of Health Care Services (DHCS) is discontinuing local modifier ZS. Modifier ZS designates both the professional (26) and technical (TC) components of a split-billable procedure on a claim or Treatment Authorization Request (TAR). When billing for both the professional and technical components, a modifier is neither required nor allowed. This change is to continue HIPAA compliance efforts and to align with the Centers for Medicare and Medicaid Services (CMS) guidelines.

Discontinuing local modifier ZS will affect claims and TARs for all split-billable procedures except for Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA) and Positron Emission Tomography (PET) procedures. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.

Note:

Providers who previously submitted claims or TARs for split-billable procedures using local modifier ZS will be instructed to submit claims and TARs without a modifier.

Claim Completion
Except for MRI, MRA or PET procedures, providers will be instructed to use one of the following methods when submitting a claim for both the professional and technical components of split-billable procedures. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.
Physician Billing: The physician bills for both the professional and technical components and then reimburses the facility for the technical component, according to their mutual agreements.
The physician submits a CMS-1500 claim form with the procedure code on one claim line without a modifier in the Procedures, Services or Supplies/Modifier field (Box 24D).
Facility Billing: The facility bills for both the technical and professional components and then reimburses the physician for the professional component, according to their mutual agreements.
The facility submits a UB-04 claim form with the procedure code on one claim line without a modifier in the HCPCS/Rate/HIPPS Code field (Box 44).
TAR Completion
Except for MRI, MRA or PET procedures, providers will be instructed to use the following method when submitting a TAR for both the professional and technical components of split-billable procedures. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.

A provider submits the TAR with the procedure code on one service line without a modifier.

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3. Payment Error Rate Measurement Program Medical Review Results

The federal fiscal year 2013 Payment Error Rate Measurement (PERM) medical review was recently completed in California by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to identify erroneous payments made in Medicaid and the Children's Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress.

During the fiscal year 2013 PERM, a total of 331 Medicaid and 372 CHIP Medi-Cal claims paid between October 1, 2012, and September 30, 2013, were selected for medical review. The majority of errors were caused by providers failing to respond to requests for medical records. The other error finding cited most frequently was submission of insufficient documentation. Nearly all of the insufficient documentation errors were due to providers not submitting either the order for a laboratory test or documentation to support a bed hold.

To reduce error findings in future PERM reviews and ensure that providers are in compliance with state and federal regulations, the Department of Health Care Services (DHCS) reminds providers of the following:

Not only do error findings affect California's payment measurement rate, but claims cited with error findings at the conclusion of the medical review are also considered improperly paid. Therefore, in accordance with W&I Code Section 14172.5, DHCS is authorized to recoup these payments. Providers who receive a demand for recovery of claim payments are urged to remit the demand amount as soon as possible.

Provider cooperation will help ensure that the payment measurement rate for future PERM reviews is accurate and that California retains its much-needed federal match monies for the Medi-Cal program.

Information about the upcoming fiscal year 2016 PERM will soon be available on the CMS PERM Providers web page and the DHCS Payment Error Rate Measurement (PERM) Program web page. Providers can email questions about PERM to DHCS at PERM@dhcs.ca.gov.

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4. Electrocardiogram CPT-4 Code 93005 Reinstated as Payable Medi-Cal Benefit

The Department of Health Care Services (DHCS) is reinstating CPT-4 code 93005 (electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report) as a payable Medi-Cal benefit for medical transport providers. Medical transport providers who received denials when billing with CPT-4 code 93005 will have their claims reprocessed in an upcoming Erroneous Payment Correction (EPC) for dates of service on or after November 1, 2014.

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5. May 2015 Medi-Cal Provider Seminars

The next Medi-Cal Provider Seminar is scheduled for May 12, 2015, at the Visalia Convention Center, Visalia, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP), clicking the seminar date(s) they would like to attend, and 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, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

In addition, 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 are encouraged to bookmark the Provider Training page and refer to it often for current seminar information.

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 your Regional Representative you must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request contact by a representative.

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