Medi-Cal Update

Obstetrics | August 2019 | Bulletin 542

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1. Telehealth Policy Update for Medi-Cal and Family PACT Programs

Effective for dates of service on or after July 1, 2019, telehealth policy is updated pursuant to Assembly Bill 415 (Logue, Chapter 547, Statutes of 2011), known as the Telehealth Advancement Act of 2011. Benefits or services covered under the Medi-Cal and Family PACT programs, identified by CPT or HCPCS codes and subject to all existing Medi-Cal and Family PACT coverage and reimbursement policies, including any Treatment Authorization Request (TAR) requirements, may be provided via a telehealth modality, if all of the following are satisfied:

Health care providers are required to document Place of Service code “02” on the claim, which indicates that services were provided or received through a telecommunications system.

Modifier GT is no longer required. Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

In addition, CPT code 99451 (interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician) is reimbursable for e-consults.

Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services – Memorandum of Agreement (IHS-MOA) 638, Clinics may also bill their respective services via a telehealth modality.

Modifier 95 is required to bill for Local Educational Agency (LEA) Medi-Cal Billing Option Program services provided via a telehealth modality.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers ind health (9–14); rural (11–16)
Chronic Dialysis Clinics modif used (2)
Clinics and Hospitals ind health (9–14); medne tele (1–11); modif used (2); rural (11–16); tar and non cd9 (9)
Family PACT ben clinic (6)
General Medicine medne tele (1–11); modif used (2); tar and non cd9 (9)
Inpatient Services tar and non cd9 (9)
Local Educational Agency loc ed bil (12); loc ed bil cd (1, 3–6, 19, 20); loc ed serv spe (6–15); loc ed tele (3)
Obstetrics modif used (2); tar and non cd9 (9)
Rehabilitation Clinics modif used (2)
Vision Care pro serv (6)
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2. Azithromycin and Ceftriaxone Are Reimbursable for PE4PW Program

Effective retroactively for dates of service on or after July 1, 2016, HCPCS codes J0696 (injection, ceftriaxone sodium, per 250 mg) and Q0144 (azithromycin dihydrate, oral, capsules/powder, 1 gram) are reimbursable for Presumptive Eligibility for Pregnant Women (PE4PW) program recipients.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum bill (14)
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3. Place of Service Code Added to Evaluation and Management Codes

Effective retroactively for dates of service on or after January 1, 2003, Place of Service code 20 (Urgent Care Facility) is added to Evaluation and Management (E&M) codes 99201 – 99215.

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
Clinics and Hospitals
General Medicine
Obstetrics
eval (7)
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4. Radium Ra-223 Dichloride Policy Update

Effective retroactively for dates of service on or after October 1, 2015, policy for HCPCS code A9606 (Radium RA-223 dichloride, therapeutic, per microcurie) is updated. The patient must be 18 years of age or older, and ICD-10-CM diagnosis code C61 is required for reimbursement. Modifier JW is allowed.

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
Clinics and Hospitals
General Medicine
Obstetrics
non ph (25); radi onc (9, 10)
Rehabilitation Clinics non ph (25)
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5. Abatacept Injection Minimum Age Restriction Update

Effective retroactively for dates of service on or after April 1, 2017, the minimum age requirement for HCPCS code J0129 (injection, abatacept, 10 mg) is updated to 2 years and older.

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
Pharmacy
Rehabilitation Clinics
inject drug a-d (1, 2)
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6. Extended End Date for Proposition 56 Supplemental Payments

Effective for dates of service on or after July 1, 2019, the Department of Health Care Services (DHCS) has extended the end date to December 31, 2021, for supplemental payments allocated under the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56).

Previously implemented supplemental payment amounts shall continue for the following CPT codes, HCPCS codes and accommodation codes:

Physician Services
Codes Amount Codes Amount Codes Amount
99201 $18.00 99214 $62.00 99384 $83.00
99202 $35.00 99215 $76.00 99385 $30.00
99203 $43.00 90791 $35.00 99391 $75.00
99204 $83.00 90792 $35.00 99392 $79.00
99205 $107.00 90863 $5.00 99393 $72.00
99211 $10.00 99381 $77.00 99394 $72.00
99212 $23.00 99382 $80.00 99395 $27.00
99213 $44.00 99383 $77.00    

Family Planning, Access, Care and Treatment (Family PACT)
Codes Amount Codes Amount Codes Amount
99201 $81.18 99204 $244.26 99213 $85.08
99202 $121.59 99211 $42.56 99214 $132.95
99203 $202.77 99212 $64.17    

Intermediate Care Facility for the Developmentally Disabled (ICF/DD)
Accommodation Codes Amount Accommodation Codes Amount
41 and 43
(1 – 59 beds)
$15.47 62 and 64 $12.47
61 and 63 $10.75 66 and 69 $22.30

Intermediate Care Facility for the Developmentally Disabled/Continuous Nursing (ICF/DD-CN)
Codes Amount Codes Amount
T2033 U8 $35.58 T2033 U9 $39.32

Women's Health (Pregnancy/Abortion)
Codes Amount Codes Amount
59840 $149.15 59841 $345.57

HIV/AIDS Waiver
Codes Amount Codes Amount Codes Amount
G0299 $9.12 G0156 $4.51 T2022 $134.06
G0300 $6.61 S5130 $3.35 T2025 $76.63
90837 $47.02 S9470 $30.13    

Free-Standing Pediatric Subacute Facility
Accommodation Codes Amount Accommodation Codes Amount
91 $132.92 94 $132.92
92 $132.92 95 $132.92
93 $132.92 96 $132.92

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

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7. BCG Vaccine is No Longer a Medi-Cal Benefit

Effective for dates of service on or after July 1, 2019, CPT code 90586 (Bacillus Calmette-Guerin vaccine [BCG] for bladder cancer, live, for intravesical use) is no longer a Medi-Cal benefit.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics immun (3); inject cd list (3)
Clinics and Hospitals
General Medicine
Obstetrics
immun (3); inject cd list (3); non ph (23); tar and non cd9 (1)
Inpatient Services tar and non cd9 (1)
Rehabilitation Clinics immun (3); inject cd list (3); non ph (23)
Pharmacy immun (3); inject cd list (3)
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8. ICD-10-CM Diagnosis Codes Added for Ovarian Oncology Biochemical Assays

Effective for dates of service on or after September 1, 2019, CPT code 81503 (oncology [ovarian], biochemical assays of five proteins [CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-albumin], utilizing serum, algorithm reported as a risk score) is reimbursable only when billed in conjunction with at least one of the following ICD-10-CM diagnosis codes:

D39.10 – D39.12 N83.202 N83.299 R19.09
N83.00 – N83.02 N83.209 R19.00  
N83.10 – N83.12 N83.291 R19.03 – R19.05  
N83.201 N83.292 R19.07  

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (59)

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9. ICD-10-CM Codes for Iron Sucrose Injection

Effective for dates of service on or after September 1, 2019, providers must use ICD-10-CM diagnosis codes D50.0 – D50.9 (Iron deficiency anemia) and N18.1 – N18.8 (Chronic kidney disease [CKD]) when billing for HCPCS code J1756 (Iron sucrose injection, 1 mg).

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

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Chronic Dialysis Clinics
Clinics and Hospitals
Pharmacy
Rehabilitation Clinics
inject drug i-m (10)
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10. Every Woman Counts Recipient Application Update: Additional Languages

The Every Woman Counts (EWC) Recipient Application (DHCS 8699, Vietnamese) is available on the Every Woman Counts (EWC) Manuals, Forms and Worksheets page and the Forms page of the Medi-Cal website. The Recipient Application (DHCS 8699) will be uploaded in additional languages in the coming months. English, Spanish and Vietnamese versions of the forms are all currently available and updated.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (6, 7, 14–16, 41)
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11. CCS Service Code Groupings Update

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

Claims require an approved Service Authorization Request (SAR) specific to the code.

End-dated Codes:
Effective Date Codes SCGs
February 1, 2018 HCPCS codes C9014, C9015, J1428 and J2326 01, 02, 03 and 07

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, 2, 13)
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12. Infliximab Injection Age Requirement Update

Effective for dates of service on or after September 1, 2019, HCPCS code J1745 (injection, infliximab, excludes biosimilar, 10 mg) is reimbursable for patients 6 years of age and older.

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 (7–9)
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13. HCPCS Code J0604 Is No Longer a Medi-Cal Benefit

Effective for dates of service on or after September 1, 2019, HCPCS code J0604 (cinacalcet, oral, 1 mg, [for ESRD on dialysis]) is no longer a Medi-Cal benefit. Cinacalcet, however, is still available to Medi-Cal recipients as a Medi-Cal pharmacy benefit.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics non inject (13, 14)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non inject (13, 14); non ph (14, 27)
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14. Physician-Administered Drugs Update

The Physician-Administered Drugs section of the Pharmacy provider manual is updated. A summary of drugs that are added is shown below.

Changed Drug(s)
Effective Date Drug Summary of Changes
July 1, 2019 BUPRENORPHINE EXTENDED-RELEASE INJECTABLE SOLUTION Restriction removed
July 1, 2019 NALTREXONE EXTENDED-RELEASE INJECTABLE SUSPENSION Restriction removed

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1, 2)
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15. 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 25, 2019 ERDAFITINIB Drug added, administration added, restrictions added drugs cdl p1b (7)
July 1, 2019 ACAMPROSATE CALCIUM Drug added, administration added drugs cdl p1a (2)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
July 1, 2019 ARSENIC TRIOXIDE Strength added, restriction added drugs cdl p1a (16)
July 1, 2019 BECLOMETHASONE DIPROPIONATE Administration removed, administration changed, strengths changed, restriction added drugs cdl p1a (21)
July 1, 2019 BENDAMUSTINE HCL Restriction added drugs cdl p1a (22)
July 1, 2019 BUDESONIDE Restriction removed, restriction added drugs cdl p1a (27)
July 1, 2019 METHOTREXATE Restriction added drugs cdl p1b (70)
July 1, 2019 NICOTINE POLACRILEX Restriction removed drugs cdl p1c (15)
July 1, 2019 OMACETAXINE MEPESUCCINATE Restriction added drugs cdl p2 (12)
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16. September 2019 Medi-Cal Provider Seminar

The September Medi-Cal Provider Seminar is scheduled for September 17 – 18, 2019, at the Visalia Convention Center in Visalia, California. Providers can access a class schedule for the seminar by visiting the Provider Training web 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 California Medicaid Management Information System (MMIS) 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 by September 3, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After September 3, 2019, 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 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 shortly after urgent announcements and other updates post 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 and select a subscriber type

  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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