Medi-Cal Update

Obstetrics | July 2017 | Bulletin 517

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2. KX Modifier Facilitates Claims for Transgender Services

Effective for dates of service on or after August 1, 2017, modifier KX (requirements specified in the medical policy have been met) may be used to facilitate claim processing in instances where the patient's gender conflicts with the billed procedure code. The patient's medical record must support medical necessity for the procedure.

Providers may already override a gender conflict with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) when the gender on the claim conflicts with the billed procedure code. Use of modifier KX introduces an alternative method to facilitate claims processing without requiring an approved TAR or SAR. The use of modifier KX will not override other policy requirements for an approved TAR or SAR.

New ‘Transgender Services’ Manual Section
More information is available in the new Transgender Services section in the appropriate Part 2, Medi-Cal Provider Manual.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path bil (18); preg early (2); radi (10); radi dia (1, 25); surg (7); surg bil mod (9); surg female (3); surg male (2); surg urin (7); surg lap (1); transgender (1, 2)
Chronic Dialysis Clinics path bil (18)
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3. CCS Service Code Groupings Update

The following codes will be end-dated from the California Children's Services (CCS) Service Code Groupings (SCGs).

End-Dated Codes:

Effective Date Code SCGs
November 1, 2016 HCPCS codes X4506, X4508, X4510, X4536, X4538 02, 03, 04, 05, 06
November 1, 2016 HCPCS codes X4512, X4514, X4516, X4518, X4524, X4528, X4546 04, 05
November 1, 2016 HCPCS code Z0316 01, 02, 03, 04, 05, 06, 07
November 1, 2016 HCPCS code Z5926 02, 03, 04, 05

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.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Clinics and Hospitals
Chronic Dialysis Clinics
Durable Medical Equipment
Community-Based Services
General Medicine
Home Health Agencies/Home and Inpatient Services
Local Educational Agency
Medical Transportation
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (1–3, 5–20, 23–29, 31)
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4. 2017 HCPCS Update for Physician Administered Drugs

Effective for dates of service on or after April 1, 2017, the following HCPCS codes are Medi-Cal benefits and are reimbursable when performed by a non-physician medical practitioner (NMP):

HCPCS Codes Description
C9484 Injection, eteplirsen, 10 mg
C9485 Injection, olaratumab, 10 mg
C9486 Injection, granisetron extended release, 0.1 mg
C9487 Ustekinumab, for intravenous injection, 1 mg
C9488 Injection, conivaptan hydrochloride, 1 mg

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
inject cd list (4, 6, 7, 12, 16); inject drug a-d (21, 22); inject drug e-h (15, 16, 24, 25); inject drug n-r (2, 3); inject drug s-z (15, 16)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (4, 6, 7, 12, 16); inject drug a-d (21, 22); inject drug e-h (15, 16, 24, 25); inject drug n-r (2, 3); inject drug s-z (15, 16); non ph (10, 22)
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5. Face-to-Face Encounter Required for DME Prescription

Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to allow reimbursement to providers only for Durable Medical Equipment (DME) items that are signed for by a physician in either written or electronic format. Additionally, a face-to-face encounter administered by a physician, nurse practitioner, clinical nurse specialist or physician assistant, related to the primary reason the recipient requires the DME item, is also required. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura (1, 4, 5); dura bil dme (3, 9, 10, 14, 22, 25); dura bil oxy (12); dura bil thp (11)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (3, 12)
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6. 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 July 1, 2017
NDC Labeler Code Contracting Company's Name
69344 EGALET US INC.
69437 CANTON LABORATORIES, LLC.
70183 LEXICON PHARMACEUTICALS, INC.
70194 SYNERGY PHARMACEUTICALS, INC.
70257 SAOL THERAPEUTICS, INC.
70370 NEUROCRINE BIOSCIENCES, INC.
70539 RADIUS HEALTH, INC.
70700 XIROMED, LLC.
70720 TERSERA THERAPEUTICS LLC

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 (18, 19)
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7. Medi-Cal List of Contract Drugs

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

A summary of drugs that have been added or 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
April 19, 2017 NIRAPARIB Drug added, administration added, restriction added drugs cdl p1c (6)
May 1, 2017 DURVALUMAB Drug added, administration added, restriction added drugs cdl p1a (65)
May 1, 2017 MIDOSTAURIN Drug added, administration added, restriction added, note added drugs cdl p1b (70)
May 12, 2017 BRIGATINIB Drug added, administration added, restriction added drugs cdl p1a (24)
May 18, 2017 RIBOCICLIB AND LETROZOLE Drug added, administration added, restriction added, note added drugs cdl p1c (42)


Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
May 1, 2017 LAMIVUDINE AND ZIDOVUDINE Restriction removed drugs cdl p1b (49)
May 15, 2017 ABIRATERONE ACETATE Restriction updated, administration added drugs cdl p1a (1)
July 1, 2017 RAMUCIRUMAB Restriction added drugs cdl p1c (40)
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8. National Correct Coding Initiative Quarterly Update for July 2017

The Centers for Medicare & Medicaid Services has released the quarterly National Correct Coding Initiative 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 July 1, 2017.

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

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9. Correction to Rate for Pulmonary Valve Implantation

Effective retroactively for dates of service on or after October 1, 2016, the reimbursement rate for CPT-4 code 33477 (transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed) is corrected.

No action is required of providers. Affected claims will be reprocessed with an Erroneous Payment Correction (EPC).

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

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10. Cardiac Magnetic Resonance Imaging Added as Diagnostic Benefit

Effective for dates of service on or after August 1, 2017, CPT-4 Code 75561 (cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences) is listed as a Medi-Cal benefit.

A Treatment Authorization Request (TAR) is required for reimbursement.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (7)
Inpatient Services tar and non cd7 (2)
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11. Lanreotide Policy Expansion to Include GEP-NETs

Effective for dates of service on or after August 1, 2017, coverage for HCPCS code J1930 (injection, lanreotide, 1 mg) has been expanded to include treatment of patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs). The dosage recommendations have also been expanded to include more specific instructions for treatment of patients with either GEP-NETs or acromegaly. The list of ICD-10-CM diagnosis codes required for authorization has also been expanded. An approved Treatment Authorization Request (TAR) is also required for reimbursement.

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 i-m (9, 10)
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12. Reminder: Avoid Printing Data in Margins of Paper Claim Forms

In order to ensure timely and accurate claims processing, providers are reminded to avoid printing data in the margin, header or footer portion of paper claim forms. Overlapping data may be misread. For example, processing has been delayed for certain claims with address information typed in the header portion of the CMS-1500 claim form.

The Billing Tips: Paper Claims page of the Medi-Cal website has been updated to reflect the above and to align with a previously published NewsFlash article titled “Reminder: Paper Claim Submission Guidelines.” For more general reminders about paper claim submission, please visit the page or call the Telephone Service Center (TSC) at 1-800-541-5555.

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13. Provider Orientation

Family PACT

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Family PACT Provider Orientation provides an overview of the Family PACT Program, provider enrollment process, program standards and benefits and client eligibility and enrollment.

Solo or group providers or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility.

Effective May 1, 2017, the Family Planning, Access, Care and Treatment (Family PACT) Program has implemented a new Provider Orientation process. The Family PACT Provider Orientation is delivered in two parts. Part one consists of an online orientation that must be completed prior to attending a part two in-person orientation. Medi-Cal providers who wish to enroll in the Family PACT Program will be required to complete both the online orientation and attend the in-person orientation. The Family PACT Provider Orientation is open to all site staff.

Complete the orientation process by following three simple steps:

  1. Visit: http://www.ofpregistration.org/ to register and create a profile in the Office of Family Planning Learning Management System (LMS). Once your profile has been set up, you are ready to proceed with the orientation.
  2. Complete part one of the orientation. Part one must be completed in order to register for the (part two) in-person orientation. Print the Certification of Completion when you have completed the online orientation.
  3. Complete part two by attending the in-person orientation. Register through the LMS and select an in-person orientation session. Site certifiers must attend the in-person orientation and are required to present photo identification during registration.

Upcoming In-Person Orientation

Sacramento
August 22, 2017
10:00 a.m. – 2:00 p.m.

Sierra Health Foundation
1321 Garden Highway
Sacramento, CA  95833

Please contact the Office of Family Planning by phone (916) 650-0414 or email us at ProviderServices@dhcs.ca.gov if you have any questions regarding the orientation process.

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

Provider Manual(s) Page(s) Updated
Family PACT prov enroll (3–5)
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14. August 2017 Medi-Cal Provider Seminar

The August Medi-Cal provider seminar is scheduled for August 15 – 16, 2017, at the Sacramento Marriott in Sacramento, 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, Department of Health Care Services (DHCS) and Conduent, the Fiscal Intermediary 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 by August 1, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After August 1, 2017, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks Web page on the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers who 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 regional representative.

Providers are encouraged to bookmark the Provider Training Web page and refer to it often for current seminar information.

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15. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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