Medi-Cal Update

Obstetrics | January 2018 | Bulletin 523

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1. 2018 CPT-4/HCPCS Annual Update: Policy Updates

The 2018 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 2018 CPT-4/HCPCS Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

For Specialty Programs, current or future benefits for updated CPT-4 and HCPCS codes are reflected in the following PDF documents:

The code additions, changes and deletions are effective for dates of service on or after February 1, 2018. Please refer to the 2018 CPT-4 and HCPCS Level II code book for complete descriptions of these codes.

HCPCS codes J7210 and J7211 will be effective for dates of service on or after April 1, 2018.

Providers should refer to the HCPCS Annual Update for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids audio (9, 10); cal child ser (1–20, 25, 26, 30–32); tax (9–12)
Adult Day Health Centers audio (9, 10)
CHDP Provider Manual chdp trans (1)
Chronic Dialysis Clinics blood (7); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); path bil (8); vaccine (4, 8)
Clinics and Hospitals allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5–7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 30, 32, 35, 36, 41, 42); preg com los (1); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Durable Medical Equipment cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7); tax (9–12)
Family PACT ben fam (23, 25, 30, 41); ben grid (3, 4, 7, 24); drug (2, 7)
General Medicine allergy (1, 2); blood (7); cal child ser (1–20, 25, 26, 30–32); chemo drug a-d (5, 6, 24, 30); chemo drug e-o (8, 9, 11, 12, 25); chemo drug p-z (16, 17); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); medne neu (3); medne pul (3); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); respir (6, 7); ster (26); surg aud (3, 4); surg bil mod (7, 8); surg cardio (5, 8); surg female (2); surg integ (5); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
cal child ser (1–20, 25, 26, 30–32)
Inpatient Services cal child ser (1–20, 25, 26, 30–32); hyst (4); ster (26); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9)
Obstetrics cal child ser (1–20, 25, 26, 30–32); eval (22); fam planning (4, 9); hyst (4); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); medi non cpt (2); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); once (5, 6, 7); path bil (8); path micro (5); path molec (2, 5, 11, 13, 19–24, 27, 30, 32, 35, 36, 41, 42); preg early (5); presum (11, 12, 15, 17, 19); radi dia (20, 22, 25); radi nuc (6); rates max (4); ster (26); surg bil mod (7, 8); surg female (2); surg lap (1); surg urin (6, 7); tar and non cd1 (3, 4); tar and non cd2 (6); tar and non cd3 (1–10); tar and non cd5 (5, 6, 8); tar and non cd6 (2, 4); tar and non cd8 (1–3); tar and non cd9 (1, 4–9); vaccine (4, 8)
Orthotics and Prosthetics cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); tax (9–12)
Pharmacy blood (7); cal child ser (1–20, 25, 26, 30–32); dura bil dme (33); dura cd (27, 46); dura cd fre (3, 5); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); presum (11, 12, 15, 17, 19); tax (9–12)
Psychological Services cal child ser (1–20, 25, 26, 30–32); psychol (2, 4)
Rehabilitation Clinics audio (9, 10); cal child ser (1–20, 25, 26, 30–32); immun (9); immun cd (1); inject cd list (2–9, 12, 15, 16); inject drug a-d (14, 20, 21, 25, 26, 29, 30); inject drug e-h (2, 16–18, 27, 29, 32); inject drug i-m (4–6); inject drug n-r (2, 3); inject drug s-z (4, 15, 17, 18); modif used (4, 10, 11); non inject (12, 13); non ph (8, 10–13, 23–25); respir (6, 7); vaccine (4, 8)
Therapies audio (9, 10); cal child ser (1–20, 25, 26, 30–32); dura cd (27, 46); dura cd fre (3, 5); ortho cd1 (25); ortho cd2 (6, 16); ortho cd fre1 (4); ortho cd fre2 (3); respir (6, 7)
Vision Care cal child ser (1–20, 25, 26, 30–32); medi non cpt (2)
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2. Every Woman Counts: KX Modifier Facilitates Claims for Transgender Services

Effective for dates of service on or after August 1, 2017, Every Woman Counts (EWC) aligns its policy for transgender services with Medi-Cal and the Family Planning, Access, Care and Treatment (Family PACT) Program and allows the use of modifier KX (requirements specified in the medical policy have been met) to facilitate claim processing in instances where the patient's gender conflicts with the billed procedure code for EWC claims. An article published in the July 2017 Medi-Cal Update titled KX Modifier Facilitates Claims for Transgender Services informed providers when to use modifier KX.

In all EWC sections, regardless of the gender stated, EWC benefits and policies apply to individuals of any gender identity as long as the procedure is medically necessary. The patient's medical record must support medical necessity for the procedure.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (9)
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3. PE4PW: Use of Paper Application Extended in Select Cases

The automated web portal for the Presumptive Eligibility for Pregnant Women (PE4PW) program implemented April 1, 2017. As a part of the implementation, providers were notified they must submit a new Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility for Pregnant Women (PE4PW) Program (MC 311, Rev. 02/17) form before assisting PE4PW applicants and submitting PE4PW eligibility transactions. Also required is completion of PE4PW Provider Computer Based Training.

For an indeterminate period qualified providers who have continued to enroll recipients using the paper form, Presumptive Eligibility for Pregnant Women Program Application (MC 263), may continue to use the paper process until their enrollment into the electronic program is finalized.

Qualified providers who have not submitted a new MC 311 and/or who have not completed the computer based training will be sent reminder letters informing them of these requirements.

A copy of the MC 311 and other helpful information about the transition to the automated PE4PW enrollment process is available on the Presumptive Eligibility for Pregnant Women page of the Medi-Cal website.

Questions concerning enrollment, computer based training and other Presumptive Eligibility for Pregnant Women issues can be sent to PE@dhcs.ca.gov.

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4. Updated Frequency Limitations and Billing Instructions for Mammography Codes

Effective for dates of service on or after February 1, 2018, CPT-4 codes 77065 (diagnostic mammography, including computer-aided detection when performed; unilateral) and 77066 (… bilateral) are limited to two screenings per year and cannot both be billed on the same day for the same recipient. All other policy for CPT-4 codes 77065 and 77066 remains the same.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (20, 22, 24–31)
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5. Presumptive Eligibility for Pregnant Women Automatic Extension

Qualified Providers (QPs) of the Presumptive Eligibility for Pregnant Women Program (PE4PW) must remind individuals to complete an application for insurance affordability programs. QPs are required to provide applicants with a Single Streamline Application during the PE4PW application process.

The Medi-Cal Eligibility Data System (MEDS) automatically extends PE4PW coverage until a Medi-Cal determination is made if the insurance affordability application is received prior to the Presumptive Eligibility (PE) period end date. If no application is received by MEDS, the PE coverage ends on the last day of the month following the month of application. If a Medi-Cal determination is made prior to the PE period end date, the PE ends on the date the determination was made regardless if Medi-Cal is approved or denied.

If the recipient experiences a lapse in coverage and states that an insurance affordability application has been filed, the QP or the recipient should contact the appropriate county office to have the PE extended. The complete list of county offices is available on the County Offices to Apply for Health Coverage, Medi-Cal, and Other Benefits page of the Department of Health Care Services website.

Questions about PE4PW automatic extension may be sent to the following email address: PE@dhcs.ca.gov.

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6. CCS Service Code Groupings Update

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

Added Codes:

Effective Date Code SCGs
January 1, 2016 CPT-4 codes 80180, 86352, 86832, 86833, 96150, 96151, 96153, 99485, 99486 02, 03
January 1, 2016 CPT-4 codes 81265, 81267, 81268
HCPCS code G0452
03

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, 5–9, 11, 12, 14–19, 25, 26, 30, 31)
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7. Diabetes Prevention Program Established for Medi-Cal

Effective July 10, 2017, Senate Bill 97 (Chapter 52, Statutes of 2017), requires the Department of Health Care Services (DHCS) to establish the Diabetes Prevention Program (DPP) within the Medi-Cal fee-for-service and managed care delivery systems, consistent with the guidelines provided by the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). The DPP curriculum will promote realistic lifestyle changes, emphasizing weight loss through exercise, healthy eating and behavior modification.

A core benefit of Medi-Cal's DPP will include 22 peer-coaching sessions over 12 months, which will be provided regardless of weight loss. Participants who achieve and maintain a minimum weight loss of 5 percent by the conclusion of the 12 month period will also be eligible to receive ongoing maintenance sessions to help them continue healthy lifestyle behaviors. SB 97 also requires that Medi-Cal providers choosing to offer DPP services comply with CDC guidance and obtain CDC recognition in connection with the National DPP.

The benefit will be available to eligible Medi-Cal recipients on January 1, 2019. DHCS is working with its Managed Care Plans, the Department of Public Health, Public Health Advocates and other interested stakeholders to discuss policy implications and potential collaborations. DHCS will begin drafting its policy and submit a CMS State Plan Amendment in 2018. To join the stakeholder list and to submit questions or comments, email DHCSDPP@dhcs.ca.gov.

DHCS is conducting a provider survey to better understand how Medi-Cal providers discuss prediabetes with their patients and to receive any comments or concerns regarding Medi-Cal's DPP benefit. DHCS would appreciate provider's feedback through a short 10-minute survey.

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8. Pulmonary Rehabilitation is a Medi-Cal Benefit

Effective for dates of service on or after February 1, 2018, HCPCS code G0424 (pulmonary rehabilitation, including exercise [includes monitoring], one hour, per session, up to two sessions per day) is a Medi-Cal benefit. Billing and reimbursement is contingent upon recipients meeting established criteria, which can be located in the Respiratory Care section of the provider manual.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Rehabilitation Clinics
non ph (8, 10, 11–28); respir (4, 9–11)
Durable Medical Equipment
Therapies
respir (4, 9–11)
Obstetrics non ph (8, 10, 11–28)
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9. DRG NICU-Surgery Policy Adjustor for State Fiscal Year 2017 – 18 and Eligibility Process for Subsequent State Fiscal Years

Welfare and Institutions Code section 14105.28 authorizes the All Patient Refined – Diagnosis Related Group (DRG) reimbursement methodology as approved by the Centers for Medicare & Medicaid Services (CMS) in pages 17.38 to 17.55 of Attachment 4.19-A of the California State Plan (State Plan). The implementation of DRG payment for inpatient services in a general acute care hospital not reimbursed by certified public expenditures (CPE) includes the functionality of DRG Neonatal Intensive Care Unit (NICU)-Surgery Policy Adjustor that adjusts DRG payment relative weights for neonatal services performed in a California Children's Services (CCS) approved Regional and Community NICU hospital. 

Effective for dates of service on or after August 15, 2017, the process for which a hospital may qualify for the Diagnosis Related Group (DRG) Neonatal Intensive Care Unit (NICU)-Surgery Policy Adjustor is changed. On August 14, 2017, the Department of Health Care Services (DHCS) published a public notice announcing these changes.

Refer to pages 3 and 4 of Appendix 6 to Attachment 4.19-A of the State Plan (Appendix 6) for the DRG NICU-Surgery Policy Adjustor and other DRG payment parameters. Appendix 6 also includes a list of hospitals approved to receive the DRG NICU-Surgery Policy Adjustor and establishes a number of conditions that these hospitals must meet to receive (and continue to receive) the DRG NICU-Surgery Policy Adjustor.

This provider bulletin implements the process changes enacted in CMS' approved SPA 17-032 that defines if and when the DRG NICU Surgery Policy Adjustor will apply to DRG-reimbursed hospitals. This provider bulletin is published under the authority specified in paragraph (2) of subdivision (f) of section 14105.28 of the Welfare and Institutions Code, which provides in part:

“Notwithstanding the rulemaking provisions of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, or any other provision of law, the department may implement and administer this section by means of provider bulletins, all-county letters, manuals, or other similar instructions, without taking regulatory action.”

This provider bulletin governs should there be a conflict between this provider bulletin and any previous DHCS published provider bulletins, all-county letters, manuals, or other similar instructions relating to Welfare and Institutions Code section 14105.28. 

How A Hospital Receives Designated NICU Status From CCS

Notice Letter (N.L.) 02-0413, April 12, 2013, sets forth a policy of care for DHCS' CCS-approved NICUs. This includes the types of interventions that NICUs may perform depending on whether or not the NICU has been approved for neonatal surgery. However, N.L. 02-0413 does not make a hospital automatically qualified for the DRG NICU-Surgery Policy Adjustor. An intervention approved under N.L. 02-0413 does not assure payment of the DRG NICU-Surgery Policy Adjustor.

CCS and the DRG Section within DHCS serve distinct roles as they pertain to NICU-Surgery hospitals. CCS will continue to review approved NICU-Surgery hospitals and evaluate new hospital applications to determine whether they meet the requisite standards to be approved to perform neonatal surgery. Upon approval by CCS, the DRG Section will review the information submitted to qualify for the DRG NICU-Surgery Policy Adjustor as a separate request through the Eligibility Process described below.

How A Hospital Qualifies for the DRG NICU-Surgery Policy Adjustor

Refer to the following Eligibility Process changes, enacted in CMS-approved State Plan Amendment (SPA) 17-032, that defines if and when the DRG NICU Surgery Policy Adjustor will apply to the following:

These policies are effective prospectively. Hospitals not currently on the CCS approved NICU surgery hospital list in Appendix 6 may receive the DRG NICU-Surgery Policy Adjustor subject to satisfaction of the requirements set forth in the “NICU Facilities Not Listed In Appendix 6” section below.

NICU Hospitals Listed In Appendix 6 That Are Approved To Receive The DRG NICU-Surgery Policy Adjustor

Appendix 6 sets forth DRG payment parameters, including the DRG NICU-Surgery Policy Adjustor for designated NICU facilities and surgery sites recognized by CCS to perform neonatal surgery. Appendix 6 includes terms and conditions that the listed hospitals must meet in order to receive (and continue to receive) the DRG NICU-Surgery Policy Adjustor.

Hospitals listed under Appendix 6 qualify for the DRG NICU-Surgery Policy Adjustor under the following conditions:

NICU Facilities Not Listed In Appendix 6

Hospitals not listed in Appendix 6 may be permitted to perform certain surgical interventions assigned to the neonate care category upon CCS approval or if the intervention is otherwise authorized in N.L. 02-0413. However, CCS approval to perform an intervention falling into the neonate care category or performing an intervention authorized under N.L. 02-0413 does not authorize payment of the DRG NICU-Surgery Policy Adjustor.

Before being eligible to receive the DRG NICU-Surgery Policy Adjustor, hospitals not listed in Appendix 6 must have completed each of the following steps:

Once the DRG Section has received the completed request, it will make its best effort to review and approve or reject it within 30 calendar days of the date the request is received. The DRG Section will promptly notify the hospital if it anticipates that the review and determination will take more than 30 calendar days or if the request will not be approved.

If the request is approved by the DRG Section, then the DRG Section-approved hospital will receive the DRG NICU-Surgery Policy Adjustor beginning the next state fiscal quarter.

Note:

The list of hospitals in Appendix 6 will be updated periodically.

How A Hospital No Longer Qualifies For The DRG NICU-Surgery Policy Adjustor

If a hospital loses its CCS neonatal surgery approval/status or is otherwise deemed by CCS as not meeting the applicable requirements set forth in the California Children's Services (CCS) Program Approved Hospitals section in the appropriate Part 2 manual, then the hospital is immediately ineligible to receive the DRG NICU-Surgery Policy Adjustor. This policy is effective on the date the neonatal surgery approval/status is lost.

Being listed in Appendix 6 does not guarantee payment of the DRG NICU-Surgery Policy Adjustor. In the event that a hospital remains listed, but has otherwise been deemed to have lost its neonatal surgery approval/status, it will not receive the DRG NICU-Surgery Policy Adjustor.

For further information or questions regarding State Fiscal Year 2017-18 DRG NICU-Surgery Policy Adjustor as well as the Eligibility Process, contact DHCS' DRG Section at drg@dhcs.ca.gov.

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10. Additional ICD-10-CM Diagnosis Codes for KIT Gene Analysis

Effective retroactively for dates of service on or after October 1, 2016, CPT-4 code 81272 (KIT [v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog], gene analysis, targeted sequence analysis) is reimbursable only when billed in conjunction with one of the following ICD-10-CM diagnosis codes: C43.70 – C43.72, C92.00 – C92.02, C92.40 – C92.42, C92.50 – C92.52, D03.70 – D03.72 or D48.1.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (13)
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11. Frequency Limit and Medical Necessity Updated for Neuropsychological Testing

Effective retroactively for dates of service on or after July 1, 2014, CPT-4 code 96118 (neuropsychological testing, per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report) is reimbursable for up to eight hours per year for any provider with a Treatment Authorization Request (TAR) or Service Authorization Request (SAR) that justifies medical necessity.

All hours must be billed on the last day of service.

An Erroneous Payment Correction (EPC) will be implemented. 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
once (7)
Psychological Services psychol (5–7)
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12. Split-Bill Modifiers Added for Ophthalmic Biometry

Effective for dates of service on or after November 1, 2017, CPT-4 code 92136 (ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation) is reimbursable with split-bill modifiers TC (technical component) and 26 (professional component).

No action is required of providers. 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
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
modif used (6)
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13. Update: Online PDF RAD and Medi-Cal Financial Summary

In early 2018 providers will be able to securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary. The PDF RADs will be available on the Medi-Cal website under the Transactions tab.

Note:

To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

Benefits of PDF RAD
There will be many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments will be made via PDF RADS. They will be informational only.

Providers should refer to future Medi-Cal Update bulletins for PDF RAD updates.

835 Transactions
Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246). The form is located on the Forms page of the Medi-Cal website. The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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14. Erroneous Treatment Delays and Denials for HIV PrEP and PEP

The Department of Health Care Services (DHCS) has recently been made aware of incidents of erroneous treatment delays and denials for HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) used to prevent seroconversion to HIV. These incidents have negatively impacted beneficiary health. In most of the identified cases the cause for delay/denial of a service was a basic lack of information/understanding related to the scope of benefits and/or claims processes involved with billing for the service.

For Medi-Cal beneficiaries enrolled in a Managed Care Plan (MCP), PrEP and PEP medications are noncapitated. These medications are billed and reimbursed as Medi-Cal fee-for-service claims for both MCP and fee-for-service beneficiaries. When used as a preventative regimen for people at risk of acquiring HIV (PrEP) or for post-exposure treatment, these medications do not require a Treatment Authorization Request (TAR) as DHCS understands the consequence of delaying or denying access to these life-altering medications.

Many of the delays and denials involve pharmacies in the MCP networks not dispensing PrEP and PEP and pharmacy staff incorrectly informing beneficiaries that PrEP and PEP are not benefits of Medi-Cal. There have also been reports of medical providers misinforming patients that PrEP treatment is not a benefit, therefore refusing to issue a prescription for the medications, and instructing patients to use condoms along with traditional safe sex practices.

DHCS encourages timely access, as delays in access to these medications may have deleterious health effects for beneficiaries, including seroconversion from HIV negative to HIV positive. It is the responsibility of pharmacy providers, medical providers and ancillary staff to be fully informed about the scope of benefits and the proper submission of claims for noncapitated drugs. DHCS requests that all Medi-Cal providers, both MCP and fee-for-service, review the scope of benefits associated with drugs used to prevent the transmission of HIV. DHCS encourages providers to take appropriate actions to ensure that all ancillary staff are equally well informed regarding the scope of benefits and the processes and procedures for providing and billing for the medications when it is medically necessary.

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15. 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 January 1, 2018
NDC Labeler Code Contracting Company's Name
50268 AVPAK
59353 VIFOR (INTERNATIONAL) INC.
60219 AMNEAL PHARMACEUTICALS
70436 SLATE RUN PHARMACEUTICALS, LLC
70709 CYCLE PHARMACEUTICALS, LTD.
70785 IRONWOOD PHARMACEUTICALS, INC.
70801 FLEXION THERAPEUTICS, INC.
70842 MELINTA THERAPEUTICS, INC
71093 ACI HEALTHCARE USA, INC.
75826 WINDER LABORATORIES, 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 (10, 13, 19, 20)
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16. 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 Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
November 1, 2017 ACALABRUTINIB Drug added, administration added, restriction added drugs cdl p1a (2)
December 4, 2017 DOLUTEGRAVIR/RILPIVIRINE Drug added, administration added, restriction added drugs cdl p1a (62)
January 1, 2018 ABEMACICLIB Drug added, administration added, restriction added drugs cdl p1a (1)
January 1, 2018 GLECAPREVIR/PIBRENTASVIR Drug added, administration added, restriction added, notes added drugs cdl p1b (28)
January 1, 2018 VARICELLA ZOSTER VACCINE Drug added, administration added, restriction added drugs cdl p1d (28)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
May 1, 2017 LISDEXAMFETAMINE DIMESYLATE Administration added drugs cdl p1b (57)
October 1, 2017 SONIDEGIB Restriction changed drugs cdl p1d (6)
January 1, 2018 NORELGESTROMIN AND ETHINYL ESTRADIOL Restriction removed, strength added drugs cdl p1c (7)
January 1, 2018 ZOSTER VACCINE Restriction changed drugs cdl p1d (34)
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17. National Correct Coding Initiative Quarterly Update for January 2018

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) 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 January 1, 2018.

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

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18. 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

Oakland
February 15, 2018
10:00 a.m. – 2:00 p.m.
California Endowment
2000 Franklin Street
Oakland, CA 94612
Sacramento
March 13, 2018
9:00 a.m. – 1:00 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.

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19. February 2018 Medi-Cal Provider Seminar

The next Medi-Cal provider seminar is scheduled for February 13 – 14, 2018, at the Ontario Airport Hotel & Conference Center in Ontario, 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, the Department of Health Care Services (DHCS) and the DHCS Fiscal Intermediary (FI) 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 and request by January 30, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After January 30, 2018, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web page of the Medi-Cal website.

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

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 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 representative.

Providers are encouraged to bookmark the Provider Training web page and refer to it often for current educational information, such as the annual provider seminar and webinar schedule, provider training workbooks, online tutorials, recorded webinars and additional curriculum on the MLP.

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20. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

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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21. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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