Medi-Cal Update
Obstetrics | May 2011 | Bulletin 443Print Medi-Cal Update
Effective retroactively for dates of service on or after January 1, 2011, the Department of Health Care Services is implementing the following new CPT-4 codes for computed tomography (CT):
| CPT-4 Code | Description | |
| 74176 | Computed tomography, abdomen and pelvis; without contrast material | |
| 71477 | with contrast material(s) | |
| 74178 | without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions | |
These codes must be used when claiming CT for both the abdomen and pelvis on the same date of service. All other CT policy applies to these codes. The codes are split-billable and require a modifier.
Providers are reminded: Claims denied with abdomen CT codes 74150, 74160 and 74170 or pelvis CT codes 72192, 72193 and 72194 should be resubmitted to include codes 74176, 74177 and/or 74178, as appropriate. When claiming CT abdomen and pelvis codes 74176 – 74178, do not claim codes 72192 – 72194 or 74150 – 74170. Claims resubmitted for these codes, prior to November 1, 2011 will not be reduced for late submission.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals
General Medicine Obstetrics |
radi dia (1) |
Providers are reminded that Medi-Cal does not pay for any bulk drugs (Active Pharmaceutical Ingredients [APIs]). A bulk drug, or API, is a "substance that is represented for use in a drug, and that when used in manufacturing, processing or packaging of a drug, becomes an active ingredient of the drug product.” (Centers for Medicare & Medicaid Services, 2011) (21 C.F.R. § 207.3 [a] [4]). Additionally, APIs do not meet the definition of covered outpatient drugs as defined in Section 1927(k)(2) of the Social Security Act. Therefore, these products are not payable benefits. In addition, excipient products used in compounds (aquaphor, petrolatum, cherry syrup, etc.) are also non-drug products and are not covered.
For billing physician-administered drugs, providers are reminded to include the National Drug Code (NDC) when billing a HCPCS/NDC combination product. Claims will be denied if the NDC is not included, and the NDC must be from an approved labeler as listed in the Drugs: Contract Drug List Part 5 – Authorized Drug Manufacturer Labeler Codes section. If the compounded injectable physician-administered drug meets these criteria, the provider should bill the drug using the appropriate HCPCS code and include supporting documentation and invoicing for approval and payment.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| General Medicine
Obstetrics |
inject bil cms (3); physician ndc (1) |
| Adult Day Health Care Centers
AIDS Waiver Program Clinics and Hospitals Chronic Dialysis Clinics Expanded Access to Primary Care Program Heroin Detoxification Home Health Agencies/Home and Community-Based Services Hospice Care Program Multipurpose Senior Services Program Rehabilitation Clinics |
physician ndc (1) |
Effective May 1, 2011, t he following codes will be added/end-dated to/from the California Children’s Services (CCS) Service Code Groupings (SCGs):
Added Code(s)
The following HCPCS codes will be added to SCGs 01, 02, 03 and 07| J0735 | J0895 | J1250 |
| J1630 | J1631 | J2675 |
| J3070 | J7335 | J9070 |
| J9320 | J9370 |
| J0290 | J2300 |
End-Dated Code(s)
The following local “X” codes will be end-dated in SCGs 01, 02, 03 and 07| X6012 | X6108 | X6274 |
| X6720 | X6810 | X7488 |
| X7522 | X7524 | X7526 |
| X7570 | X7572 | X7574 |
| X5550 | X5576 | X5578 |
| X5580 | X5582 | X5584 |
| X5586 | X5588 | X6612 |
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 and Medical Supplies 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 (1–4, 24) |
The Genetically Handicapped Persons Program Provider (GHPP) section has been updated to include new instructions for Service Code Groupings (SCGs), additional information about the types of Service Authorization Request (SAR) forms and drugs and nutritional products requiring separate authorization, as well as SAR requirements for Durable Medical Equipment, medical supplies and Home Health Agencies.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Inpatient Services
General Medicine Obstetrics Clinics and Hospitals Chronic Dialysis Clinics Home Health Agencies/Home and Community-Based Services Local Educational Agency Rehabilitation Clinics Audiology and Hearing Aids Durable Medical Equipment and Medical Supplies Medical Transportation Orthotics and Prosthetics Psychological Services Therapies Pharmacy Vision Care |
genetic (1, 3–10, 13) |
The Centers for Medicare & Medicaid Services (CMS) released the quarterly National Correct Coding Initiative (NCCI) edit updates. These mandatory national edits were incorporated into the Medi-Cal claims processing system and applied to claims beginning April 1, 2011. The Medi-Cal claims processing system already applies many of the same edits to claims as NCCI. However, it is expected the NCCI edits will further impact reimbursement for some claims.
NCCI edits are designed to prevent inappropriate reimbursement of services including, but not limited to services that are:
Information released by Medi-Cal about NCCI is supplemental only. Providers must use the CMS website (NCCI Edits Overview) as their primary source of NCCI information. Additional NCCI information is available as follows:
Medi-Cal providers seeking enrollment in the Family PACT (Planning, Access, Care and Treatment) Program are required to attend a Provider Orientation and Update Session. Dates for upcoming sessions are listed below. Registration opens at 8 a.m., with Session I beginning promptly at 8:30 a.m.
Individual and group providers wishing to enroll must send a physician-owner to the session. Non-profit and government clinics seeking to enroll must send their medical director, physician or nurse practitioner who is responsible for oversight of medical services rendered at the service site where the provider wants to enroll.
Office staff members, such as clinic managers, billing supervisors and client eligibility enrollment supervisors, are encouraged to attend. However, these staff members are not eligible to receive a Certificate of Attendance. Enrolled clinicians and staff are encouraged to attend to remain current with program policies and services.
Session Format
Family PACT has created a new session format, which offers an option for currently enrolled providers and staff to attend only the afternoon update session, along with either the clinical session or the billing and coding session.
Session I – Overview of the Family PACT Program:
| Start Time | 8:30 a.m. to 2 p.m. |
| Instructions | Attendance at this presentation is mandatory for clinician providers wishing to enroll in Family PACT and is recommended for other staff who are new to the program or need a refresher. |
Note: The afternoon sessions will run concurrently from 2 p.m. to 4 p.m.
Session II – Clinical Practice Alerts:
| Start Time | 2 p.m. to 4 p.m. |
| Instructions | Clinicians in attendance who wish to become Family PACT providers must also attend this session. Free continuing education (CE) credit is available for Session II. Providers must bring their medical license number if requesting CE credit; a continuing education request form will be available during onsite registration. Other interested clinical staff are welcome to attend and may request free CE credit for this session. |
Session III – Tips for Successful Family PACT Administration:
| Start Time | 2 p.m. to 4 p.m. |
| Instructions | Administrators and billers interested in Family PACT Program administration and billing information may attend. |
Please note the upcoming Provider Orientation and Update Sessions below.
| Mendocino June 9, 2011 8:30 a.m. – 4 p.m. The Stanford Inn 44855 Comptche Ukiah Road Mendocino, CA 95460 1-800-331-8884 |
Los Angeles July 7, 2011 8:30 a.m. – 4 p.m. Radisson LAX 6225 West Century Boulevard Los Angeles, CA 90045 (310) 670-9000 |
San Luis Obispo July 21, 2011 8:30 a.m. – 4 p.m. Embassy Suites 333 Madonna Road San Luis Obispo, CA 93405 (805) 549-0800 |
| Oakland August 16, 2011 8:30 a.m. – 4 p.m. California Endowment 1111 Broadway, 7th Floor Oakland, CA 94607 (510) 271-4333 |
Anaheim August 23, 2011 8:30 a.m. – 4 p.m. Embassy Suites 11767 Harbor Boulevard Garden Grove, CA 92840 (714) 539-3300 |
Bakersfield September 29, 2011 8:30 a.m. – 4 p.m. Marriott 801 Truxtun Avenue Bakersfield, CA 93301 (661) 323-1900 ext 1001 |
| Palm Springs November, 2011 8:30 a.m. – 4 p.m. Hyatt Regency Suites 285 North Palm Canyon Drive Palm Springs, CA 92262 (760) 322-9000 |
For a map and directions to these locations, providers can go to the Family PACT website and click “Directions and Map of Location” for the appropriate session location.
Registration
To register for an orientation and update session, providers should:
Providers with no Internet access may request the registration form by calling 1-877-FAMPACT (1-877-326-7228). Providers must supply the following when registering:
Check-In
Check-in begins at 8 a.m. All orientation sessions start promptly at 8:30 a.m. and end by 4 p.m. At the session, providers must present the following:
Note: Individuals representing a clinic or physician group should use the clinic or group NPI, not an individual NPI or license number.
Certificate of Attendance
Upon completion of the orientation session, each prospective new Family PACT medical provider will receive a Certificate of Attendance. Providers should include the original copy of the Certificate of Attendance when submitting the Family PACT application and agreement forms (available at the session) to Family PACT Provider Enrollment. Providers arriving late or leaving early will not receive a Certificate of Attendance. Currently enrolled Family PACT providers do not receive a certificate.
Contact Information
For more information about the Family PACT Program, please call 1-877-FAMPACT (1-877-326-7228) or visit the Family PACT website.
The Family PACT Program was established in January 1997 to expand access to comprehensive family planning services for low-income California residents.
Effective for dates of service on or after June 1, 2011, CPT-4 codes 80100, 80101 and 80104 and HCPCS code G0430 will no longer be reimbursable for laboratory services. HCPCS code G0434 replaces code G0430 for relatively simple point-of-care tests that screen for multiple substances and may be billed with modifier QW (CLIA-waived) when a CLIA-waived kit is used. Code G0434 is split-billable and may be billed with modifiers 26, TC and ZS.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| General Medicine Obstetrics Clinics and Hospitals |
hcpcs ii (3); path bil (6); path drug (1–3); presum (17, 21) |
| Chronic Dialysis Clinics | hcpcs ii (3); path bil (6) |
| Pharmacy | presum (17, 21) |
Effective for dates of service on or after June 1, 2011, the minimum age for adults to receive the zoster vaccine (Zostavax), billed with CPT-4 code 90736 (Zoster [Shingles] vaccine, live for subcutaneous injection), is lowered from 60 years of age to 50 years of age.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine Obstetrics Rehabilitation Clinics Chronic Dialysis Clinics Pharmacy |
immun (12) |
Providers are reminded that the price listed on the Medi-Cal Rates page of the Medi-Cal website for each Physician Administered Drug includes the one-time administration fee of $4.46 for injections. Since the administration fee is paid only once for each drug administered, subsequent units claimed must have the administration fee subtracted from the published rate.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals Chronic Dialysis Clinics Medical Services Pharmacy Rehabilitation Clinics |
inject an over (1) |
| Clinics and Hospitals General Medicine |
chemo an over (1) |
The following provider manual sections have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications Drugs.
| Drug | Strength and/or Size | Billing Unit | ||||
| Addition, effective May 1, 2011 | ||||||
| FESOTERODINE FUMARATE | ||||||
| Tablet, extended release (24-hour) | 4 mg | ea | ||||
| 8 mg | ea | |||||
| Change, effective October 1, 2010 | ||||||
| LEVOFLOXACIN | ||||||
| * | Ophthalmic solution | 0.5 % | 2.5 ml | ml | ||
| 5.0 ml | ml | |||||
| * | Restricted to claims with dates of service from July 1, 2001 through September 30, 2010 |
|||||
| 1.5 % | 5.0 ml | ml | ||||
| * | Tablets | 250 mg | ea | |||
| 500 mg | ea | |||||
| 750 mg | ea | |||||
| * | Restricted to a maximum quantity per dispensing of ten (10) tablets and a maximum of two (2) dispensings in any 30-day period and restricted to NDC labeler codes 00045 (McNeil Pharmaceutical dba Ortho-McNeil Pharmaceutical, Inc.) and 50458 (Ortho-McNeil Janssen Pharmaceuticals, Inc.) for tablets only. | |||||
| Change, effective May 1, 2011 | ||||||
| ‡ GANCICLOVIR | ||||||
| |
||||||
| * | Capsules | 250 mg | ea | |||
| 500 mg | ea | |||||
| * | Restricted to use in the treatment of AIDS-related conditions for the capsules only. | |||||
| * | Ophthalmic gel | 0.15 % | Gm | |||
| * | Restricted to NDC labeler code 24208 (Bausch & Lomb Pharmaceuticals, Inc.) only and to use for the treatment of acute herpetic keratitis (dendritic ulcers). Also restricted to a maximum of one tube (5 grams) per dispensing and a maximum of two dispensings in any 12-month period for the ophthalmic gel only. | |||||
| Changes, effective July 1, 2011 | ||||||
| * TIMOLOL MALEATE | ||||||
| Ophthalmic drops | 0.25 % | single use | ea | |||
| 0.5 % | single use | ea | ||||
| * | Ophthalmic drops (formulated with potassium sorbate) | 0.5 % | ml | |||
| * | Restricted to NDC labeler code 67425 (Ista Pharmaceuticals) only and to dates of service from May 1, 2005 through June 30, 2011. | |||||
| Ophthalmic gel | 0.25 % | |||||
| 0.5 % | ||||||
| + | Tablets | 5 mg | ea | |||
| 10 mg | ea | |||||
| 20 mg | ea | |||||
This information is reflected in the following provider manual:
| Provider Manual(s) | Page(s) Updated |
| Pharmacy | drugs cdl p1b (12, 19, 40); drugs cdl p1d (13); drugs cdl p4 (19) |
The Center for Medicare and Medicaid Services (CMS) recently issued a bulletin clarifying their position on compounding of hydroxyprogesterone caproate. The intent of the CMS bulletin was to inform states that the Food and Drug Administration (FDA) does not intend to take enforcement action against pharmacies that compound hydroxyprogesterone caproate for individuals possessing a valid prescription unless that product is unsafe, substandard in quality, or is out of accordance with the standards for producing compounded sterile products.
Under the guidance of both CMS and FDA, DHCS policy regarding reimbursement of compounded hydroxyprogesterone caproate remains unchanged and can be found in the Pregnancy: Early Care and Diagnostic Services section of the Medi-Cal Obstetrics Provider Manual Part 2.
Effective for dates of service on or after June 1, 2011, HCPCS code Q2040 (IncobotulinumtoxinA [Xeomin]) is a new Medi-Cal benefit. IncobotulinumtoxinA is used in the treatment of adults with cervical dystonia and blepharospasm in adults previously treated with onabotulinumtoxinA (BOTOX).
Providers must bill with HCPCS code Q2040, document the medical necessity and include an approved Treatment Authorization Request (TAR).
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject cd list (9); inject drug a-l (36–38) |
Effective immediately, the reimbursement rate for HCPCS code A9543 (Zevalin [Y-90 Ibritumomab], Yttirum Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries) will change. Providers may visit the Rates area of the Medi-Cal website for more information.
Effective immediately, the use of OnabotulinumtoxinA (Botox) is reimbursable for the treatment of prophylaxis of headaches in adult patients with chronic migraine (15 or more days per month with headache lasting four hours a day or longer).
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject drug m-z (5) |
Effective May 1, 2011, Primary Care Providers (PCPs) are required to assess the tobacco use of every woman screened through Cancer Detection Programs: Every Woman Counts (CDP: EWC) and refer those who use tobacco to a smoking cessation program such as the California Smokers Helpline 1-800-NO-BUTTS (1-800-662-8887).
CDP: EWC Recipient Eligibility Form (CDPH 8699) has been updated to include a section that will indicate a woman’s tobacco use status and need for referral. Additionally, the form has been updated to indicate the age of eligibility for women receiving breast cancer screening has been changed back to 40 years and older. Also, as required by the Information Practices Act of 1977 and the Federal Privacy Act, a Privacy Statement explaining how the information on the form may be used has been added as a third page to the form.
The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.
| Addition, effective April 1, 2011 | |
| NDC Labeler Code | Contracting Company’s Name |
| 51167 | VERTEX PHARMACEUTICALS, INC. |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Pharmacy | drugs cdl p5 (10) |
Pages updated due to ongoing provider manual revisions:
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