Medi-Cal Update

Obstetrics | May 2017 | Bulletin 515

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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. New Benefit: SMN1/SMN2 Gene Test

Effective for dates of service on or after June 1, 2017, the SMN1/SMN2 gene test (CPT-4 code 81401, molecular pathology procedure, Level 2) is a Medi-Cal benefit with Treatment Authorization Request (TAR) or Service Authorization Request (SAR) approval.

CPT-4 code 81401 requires providers to document the following on the TAR or SAR, or an attachment to the TAR or SAR:

SMN1/SMN2 (survival of motor neuron 1, telomeric/survival of motor neuron 2, centromeric), dosage analysis. Patient who is considering pregnancy or is already pregnant.

This service is not covered by Medicare and may be billed directly to Medi-Cal.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (20)
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6. SMN1 Gene Tests Clarified for Molecular Pathology

Effective for dates of service on or after June 1, 2017, provider manual text in the entries under SMN1 (survival of motor neuron 1 telomeric) has been clarified regarding gene tests for three CPT-4 codes in molecular pathology. The clarified text is as follows:

CPT-4 Code Description Clarified Language
81400 Molecular pathology procedure, Level 1 Exon 7 deletion
81403 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Known familial sequence variant(s) – The patient has clinical features suspicious for, or requires the service as a confirmatory test for spinal muscular atrophy
81405 Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis Full sequence analysis

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (17, 22, 27)
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7. Respiratory Virus Laboratory Test Code Added to CLIA-Waived List

Effective for dates of service on or after June 1, 2017, CPT-4 code 87633 (infectious agent detection by nucleic acid; respiratory virus, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets) is reimbursable as a Clinical Laboratory Improvement Amendments (CLIA)-waived test when performed with a CLIA-waived test kit and billed with modifier QW (CLIA waived test). This code may also be used without modifier QW if used to bill for services that are not CLIA-waived.

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
path bil (11)
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8. Update to Rates for Select Pathology and Cytopathology CPT-4 Codes

Effective for dates of service on or after December 1, 2016, reimbursement rates have been established for CPT-4 codes 88112 (cytopathology, selective cellular enhancement technique with interpretation, except cervical or vaginal) and 88333 (pathology consultation during surgery; cytologic examination, initial site).

Affected claims will be reprocessed with an Erroneous Payment Correction (EPC) for dates of service on or after December 1, 2016.

For more information, providers may refer to the Medi-Cal Rates web page on the Medi-Cal website.

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9. 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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10. Update to Reimbursement Rate for Debridement Surgery

Effective for dates of service on or after January 1, 2017, the rate for CPT-4 code 11042 (debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) will be updated on the Medi-Cal Rates Web page on the Medi-Cal website.

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

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11. 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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12. Updated PE4PW Patient Fact Sheet Available in 12 Languages

The Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet is updated and available in 12 languages:

Providers can access the updated fact sheets on the Presumptive Eligibility for Pregnant Women and Forms pages of the Medi-Cal website.

Providers are encouraged to frequently check the Medi-Cal website for updates.

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13. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs, Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
March 15, 2017 RIBOCICLIB Drug added, administration added, restriction added, note added drugs cdl p1c (42)
April 1, 2017 TEMSIROLIMUS Drug added, administration added, restriction added drugs cdl p1d (11)

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2017 DESOGESTREL AND ETHINYL ESTRADIOL Restriction added drugs cdl p1a (54)
January 1, 2017 DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM Restriction added drugs cdl p1a (65)
January 1, 2017 ESTRADIOL VALERATE/DIENOGEST Restriction added drugs cdl p1b (10)
January 1, 2017 ETHYNODIOL DIACETATE AND ETHINYL ESTRADIOL Restriction added drugs cdl p1b (12)
January 1, 2017 LEVONORGESTREL Restriction changed drugs cdl p2 (10)
January 1, 2017 LEVONORGESTREL AND ETHINYL ESTRADIOL Restriction added drugs cdl p1b (55)
January 1, 2017 NORETHINDRONE Restriction added drugs cdl p1c (7)
January 1, 2017 NORETHINDRONE ACETATE AND ETHINYL ESTRADIOL Restriction added drugs cdl p1c (7)
January 1, 2017 NORETHINDRONE AND ETHINYL ESTRADIOL Restriction added drugs cdl p1c (8)
January 1, 2017 NORETHINDRONE AND MESTRANOL Restriction added drugs cdl p1c (10)
January 1, 2017 NORGESTIMATE AND ETHINYL ESTRADIOL Note added drugs cdl p1c (10)
January 1, 2017 NORGESTREL AND ETHINYL ESTRADIOL Restriction added drugs cdl p1c (11)
April 1, 2017 TRASTUZUMAB Restriction added drugs cdl p1d (20)
May 1, 2017 AMPHETAMINE, MIXED SALTS (AMPHETAMINE SULFATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND DEXTROAMPHETAMINE SACCHARATE) Name changed, restriction removed, restriction added drugs cdl p1a (12)
May 1, 2017 DARUNAVIR Restriction added drugs cdl p1a (52)
May 1, 2017 EMTRICITABINE Restriction added drugs cdl p1b (3)
May 1, 2017 EMTRICITABINE/RILPIVIRINE/TENOFOVIR DISOPROXIL FUMARATE Restriction added drugs cdl p1b (3)
May 1, 2017 EMTRICITABINE AND TENOFOVIR DISOPROXIL FUMARATE Restriction added drugs cdl p1b (4)
May 1, 2017 LAMIVUDINE AND ZIDOVUDINE Restriction added drugs cdl p1b (49)
May 1, 2017 LISDEXAMFETAMINE DIMESYLATE Restriction changed drugs cdl p1b (57)
May 1, 2017 MEPERIDINE HCL Restriction added drugs cdl p1b (64)
May 1, 2017 PEMETREXED Restriction added drugs cdl p1c (22)
May 1, 2017 REGORAFENIB Restriction added drugs cdl p1c (40)
May 1, 2017 SONIDEGIB Restriction added drugs cdl p1d (6)
June 1, 2017 GOSERELIN ACETATE Restriction added drugs cdl p1b (29)
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14. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
70199 CASPER PHARMA LLC
70504 APTEVO BIOTHERAPEUTICS LLC
70839 NODEN PHARMA USA, INC.
70860 ATHENEX PHARMACEUTICAL DIVISION, LLC
Terminations, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
60842 KALEO, INC.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (13, 18, 19)
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15. 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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16. 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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17. 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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18. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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