Medi-Cal Update

Obstetrics | September 2017 | Bulletin 519

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1. 2017 CPT-4/HCPCS Annual Update: Manual Replacement Page Release

The 2017 updates to the Current Procedural Terminology – 4th edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the 2017 CPT-4/HCPCS 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 will be effective for dates of service on or after October 1, 2017. Please refer to the 2017 CPT-4 and HCPCS Level II code books for complete descriptions of these codes.

Additionally, the 2017 CPT-4 codebook was updated to allow separate reimbursement for moderate (conscious) sedation for multiple codes that had previously included moderate (conscious) sedation as an inherent part of providing the procedure. Please refer to the 2017 CPT-4 codebook for instructions on how to bill for this service with other codes.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
medi cr op pr (7)
Audiology and Hearing Aids tax (7, 8)
Chronic Dialysis Clinics immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); medi non cpt (1, 2); modif used (4–7, 9–12); non inject (9–11); path bil (1, 4–7, 9); path organ (9); vaccine (2–4, 9)
Clinics and Hospitals altern (3); anest (11, 13, 16, 28); cardio (14–16, 19); chemo drug a-d (8, 9, 21); chemo drug e-o (2, 3, 10, 11, 17); chemo drug p-z (10, 12–14, 18); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); medi non cpt (1, 2); medne non (1); medne oto (4); medne tele (4, 5); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); ophthal (2); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); respir (4, 7); surg (2, 5); surg bil mod (7, 8); surg bill ub (5, 6, 10, 11); surg cardio (2, 3, 9); surg integ (4, 5); surg muscu (1, 7); surg nerv (1); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Durable Medical Equipment dura bil wheel (4, 5); dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho cd1 (12–14); ortho cd fre1 (1, 2); respir (4, 7); tax (7, 8)
General Medicine altern (3); anest (11, 13, 16, 28); cardio (14–16, 19); chemo drug a-d (8, 9, 21); chemo drug e-o (2, 3, 10, 11, 17); chemo drug p-z (10, 12–14, 18); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi non cpt (1, 2); medne non (1); medne oto (4); medne tele (4, 5); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); ophthal (2); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); respir (4, 7); surg (2, 5); surg bil cms (4, 5, 8, 9); surg bil mod (7, 8); surg cardio (2, 3, 9); surg integ (4, 5); surg muscu (1, 7); surg nerv (1); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Inpatient Services tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8)
Obstetrics altern (3); anest (11, 13, 16, 28); eval (17); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi non cpt (1, 2); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); once (6); path bil (1, 4–7, 9); path drug (2–4); path molec (10, 11, 22, 36, 37); path organ (9); presum (10, 15, 17, 18); radi (2); radi dia (24–26, 28, 29, 31); radi dia ult (3); radi nuc (6, 7); radi onc (2–4, 7); surg (2, 5); surg bil cms (4, 5, 8, 9); surg bil mod (7, 8); tar and non cd1 (2); tar and non cd2 (2, 4, 5); tar and non cd3 (2, 7, 8); tar and non cd6 (2, 5); tar and non cd8 (2, 3); tar and non cd9 (1, 5, 6, 8); vaccine (2–4, 9)
Orthotics and Prosthetics dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho (22); ortho cd1 (12–14); ortho cd fre1 (1, 2); tax (7, 8)
Pharmacy dura bil wheel (4, 5); dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8, 9, 10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); ortho (22); ortho cd1 (12–14); ortho cd fre1 (1, 2); presum (10, 15, 17, 18); tax (7, 8)
Psychological Services psychol cd (1); psychol ex (2)
Rehabilitation Clinics immun (9, 10, 19); immun cd (1, 2); inject cd list (2, 3, 5, 6, 8, 9, 11, 12, 14–16); inject drug a-d (6, 8–10, 33); inject drug e-h (21, 22, 28, 30); inject drug i-m (6, 13); inject drug n-r (11, 12); inject drug s-z (2, 15); inject hydra (2); medi cr op pr (7); modif used (4–7, 9–12); non inject (9–11); non ph (8, 10–12, 21–24); respir (4, 7); vaccine (2–4, 9)
Therapies dura cd (4, 6, 23, 25, 28–30, 33, 35, 39); dura cd fre (1); ortho cd1 (12–14); ortho cd fre1 (1, 2); respir (4, 7)
Vision Care medi non cpt (1, 2)
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2. Age Restriction and Gender Specification Updates for EWC Diagnosis Services

A NewsFlash article published in December 2016 announced the removal of age restrictions for Every Woman Counts (EWC) breast cancer diagnosis codes effective for dates of service on or after January 1, 2017.

Additionally, effective retroactively for dates of service on or after January 1, 2017, in accordance with Assembly Bill 1795, EWC will provide breast diagnostic services to all symptomatic individuals regardless of identified gender.

An Erroneous Payment Correction (EPC) will be implemented 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
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (1, 2, 5–8, 11, 14, 15)
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3. Alert: Online Report to the Vaccine Adverse Event Reporting System (VAERS)

A new DUR Educational Article titled “Alert: Online Report to the Vaccine Adverse Event Reporting System (VAERS)” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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4. 2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines

A new DUR Educational Article titled “2017 Immunization Updates: Influenza, HepA, Meningococcal, HPV, Adult Vaccines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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5. 58661 and 58700 New Benefits for Family PACT and TAR Removed for Medi-Cal

Effective for dates of service on or after October 1, 2017, CPT-4 codes 58661 (laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) and 58700 (salpingectomy, complete or partial, unilateral or bilateral) are Family Planning, Access, Care, and Treatment (Family PACT) Program benefits.

CPT-4 codes 58661 and 58700 are reimbursable for females only with ICD-10-CM diagnosis code Z30.2 (encounter for sterilization). Sterilization Consent Form (PM 330) is required. If CPT-4 codes 58661 and 58700 are elective sterilization procedures, there is no Treatment Authorization Request (TAR) requirement under the Family PACT and Medi-Cal programs.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
ster (20)
Family PACT ben fam (39, 40); ben grid (7)
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6. 2017 CPT-4/HCPCS Codes Annual Update for Family PACT

The 2017 updates to the Current Procedural Terminology - 4th Edition (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) National Level II codes are effective for the Family Planning, Access, Care, and Treatment (Family PACT) Program  for dates of service on or after October 1, 2017. The updates are as follows:

Terminated CPT-4 Code Description Replacement
CPT-4 Code
Description
99144 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time; 99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older
99145 each additional 15 minutes intra-service time 99153 each additional 15 minutes intra-service time (List separately in addition to code for primary service)

Additionally, the following HCPCS code descriptions have been updated.

HCPCS Code Description
J7297 Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg.
J7298 Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg.
J7301 Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (4, 8)
Family PACT ben fam (24, 30, 39, 50); ben grid (4, 24); drug (2, 6)
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7. New Surgical and Preventative Preterm Birth Benefits

Effective for dates of service on or after July 1, 2017, the following HCPCS codes are benefits:

HCPCS Code Description
C9745 Nasal endoscopy, surgical; balloon dilation of Eustachian tube
C9746 Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed
C9747 Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU)
Q9985 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
Q9986 Injection, hydroxyprogesterone caproate (Makena), 10 mg

Additionally, HCPCS code J1725 (injection, hydroxyprogesterone caproate, 1 mg) is no longer a Medi-Cal benefit.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
inject drug e-h (29); presum (18); preg early (5)
Chronic Dialysis Clinics
Rehabilitation Clinics
inject drug e-h (29)
Pharmacy inject drug e-h (29); presum (18)
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8. Siltuximab Added as a New Medi-Cal Benefit

Effective retroactively for dates of service on or after January 1, 2016, HCPCS code J2860 (injection, siltuximab, 10 mg) is a Medi-Cal benefit. An approved Treatment Authorization Request (TAR) is 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 s-z (3)
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9. 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
April 1, 2017 HCPCS codes X7700, X7702 01, 02, 03, 07, 12

The following codes will be added to the California Children's Services (CCS) Service Code Groupings (SCGs).

Added Codes:
Effective Date Code SCGs
April 1, 2017 HCPCS codes J7030, J7040, J7042, J7050, J7060, J7070, J7120 01, 02, 03, 07, 12

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.

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 ser (1–3, 28, 29)
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10. Update to Guidelines for SAR and eSAR Submission

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can submit Service Authorization Requests (SARs) in an electronic format for fee-for-service claims. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit electronic SARs (eSARs), providers must:

Then select one of the submission options:

  1. Utilize the newly enhanced online fillable form of the PEDI system to submit SARs electronically
  2. Generate and submit one of the supported file-based transmission formats:
    • Web-based file upload utility in the eSAR system to submit ASC X12 278 transactions
    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 278 transactions

Registered providers, clearinghouses or Managed Care Plans can complete and submit the eSAR requests on behalf of the providers and facilities in their network.

Paper SAR submissions remain an option for low-volume SAR providers or submitters who may have technical limitations or other practical reasons to do so.

Providers interested in converting from paper SAR to eSAR submission should contact the CMS Net Help Desk at cmshelp@dhcs.ca.gov or 1-866-685-8449 for helpful guidance and additional information.

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 (1, 12); genetic (4, 5)
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11. Required Modifier Included for Magnetic Resonance Imaging 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) was added as a Medi-Cal benefit. However the required modifiers, TC (technical only) and/or 26 (professional only), were mistakenly not included with the policy in the provider manual. This has been corrected.

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)
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12. Update to Reimbursement Rates for Clinical Laboratory Services

Effective for dates of service on or after July 1, 2017, Medi-Cal reimbursement rates for clinical laboratory services are updated.

No action is required of providers. Affected claims will be reprocessed via an Erroneous Payment Correction.

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

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13. Clinical Review: Drug-Induced QT Interval Prolongation

A new DUR Educational Article titled “Clinical Review: Drug-Induced QT Interval Prolongation” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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14. Medi-Cal List of Contract Drugs

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.

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 Drugs
Effective Date Drug Summary of Changes Page(s) Updated
March 27, 2017 AVELUMAB Drug added, administration added, strength added, restriction added drugs cdl p1a (18)
July 3, 2017 RITUXIMAB AND HYALURONIDASE HUMAN Drug added, administration added, strength added, restriction added drugs cdl p1c (44)
September 1, 2017 GLYCOPYRROLATE AND FORMOTEROL FUMARATE Drug added, administration added, strength added drugs cdl p1b (29)
October 1, 2017 OMBITASVIR/
PARITAPREVIR/
RITONAVIR/
DASABUVIR
Drug added, administration added, restriction added, strength added, note added drugs cdl p1c (14)

Changed Drugs
Effective Date Drug Summary of Changes Page(s) Updated
July 27, 2017 METHOTREXATE Administration added, strength added, restriction added drugs cdl p1b (67)
September 1, 2017 CEFIXIME Administration added drugs cdl p1a (33)
September 1, 2017 IVERMECTIN Restriction added drugs cdl p1b (47)
January 1, 2018 TAMOXIFEN CITRATE Restriction added drugs cdl p1d (9)
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15. 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.

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

Los Angeles Oakland Los Angeles
October 3, 2017 October 25, 2017 December 5, 2017
10:00 a.m. – 2:00 p.m. 10:00 a.m. – 2:00 p.m. 1:00 p.m. – 5:00 p.m.
California Endowment California Endowment California Endowment
1000 North Alameda Street 2000 Franklin Street 1000 North Alameda Street
Los Angeles, CA  90012 Oakland, CA  94612 Los Angeles, CA  90012

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.

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16. October 2017 Medi-Cal Provider Seminar

The October Medi-Cal provider seminar is scheduled for October 17, 2017, at the Embassy Suites in San Luis Obispo, 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 October 3, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After October 3, 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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17. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails for urgent announcements and other updates shortly, after posting on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form
  2. Enter your email address and ZIP code
  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

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18. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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