Medi-Cal Update

Obstetrics | October 2019 | Bulletin 544

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1. Alert: New Global Guidelines for the Treatment of Asthma

A new DUR Educational Article titled “Alert: New Global Guidelines for the Treatment of Asthma” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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2. Certain Induce Abortion Procedure Codes Exempt from Payment Reduction

Effective retroactively for dates of service on or after July 1, 2017, CPT codes 59840 (induced abortion, by dilation and curettage) and 59841 (induced abortion, by dilation and evacuation) are exempt from the 10 percent provider payment reduction authorized by Assembly Bill 97 (Chapter 3, Statutes of 2011).

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

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3. Drug Onasemnogene Abeparvovec-xioi Requires Own SAR

Effective for dates of service on or after May 1, 2019, the drug onasemnogene abeparvovec-xioi is excluded from any California Children’s Services and Genetically Handicapped Persons Program (GHPP) Service Code Grouping (SCG). Therefore, providers must submit a separate Service Authorization Request (SAR) for the drug.

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 (7, 8); genetic (11)
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4. Clarification: EWC Covered Procedures Quick Reference Sheets Update

A previously published article titled “EWC Covered Procedures Quick Reference Sheets Update” notified providers of updates to the Every Woman Counts (EWC) quick reference sheets. In addition to those updates, CPT code 87625 (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed) was added to the following EWC quick reference sheets:

CPT code 10022 (fine needle aspiration; with imaging guidance) was also removed from the two sheets listed above as well as from the Breast Only Primary Care Provider Covered Procedures (DHCS 8471) quick reference sheet.

These forms can be found on the Every Woman Counts (EWC) Manuals, Forms and Worksheets page of the Medi-Cal website.

Additionally, the following CPT codes were erroneously excluded from Figure 3 in the Every Woman Counts section of the appropriate Part 2 manual: CPT codes 19286 (placement of breast localization device(s), percutaneous; each additional lesion, including ultrasound guidance), 87625 (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], types 16 and 18 only, includes type 45, if performed) and 88164 (cytopathology, slides, cervical or vaginal [the Bethesda System]; manual screening under physician supervision). These codes may be billed to EWC by referral 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 (40)
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5. ICD-10-CM Diagnosis Codes Added for BRAF Gene Analysis

Effective for dates of service on or after November 1, 2019, ICD-10-CM diagnosis codes C33, C34.00 – C34.92 are reimbursable when submitted with once-in-a-lifetime CPT code 81210: BRAF (B-Raf proto-oncogene, serine/threonine kinase), gene analysis, V600 variant(s).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (12)
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6. TAR Requirements Updated for Gene Analysis Benefit

Effective for dates of service on or after November 1, 2019, the Treatment Authorization Request (TAR) criteria and billing requirements for CPT code 81162 (BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis) have been updated to include 2019 U.S. Preventive Services Task Force (USPSTF) recommendations.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (3)
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7. Evocative and Suppression Panel Tests Now Medi-Cal Benefits

Effective for dates of service on or after November 1, 2019, CPT codes 80400-80439 (evocative/suppression panel tests) have been added as a Medi-Cal benefits.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
non ph (9); path bil (19); tar and non cd8 (1)
Inpatient Services tar and non cd8 (1)
Rehabilitation Clinics non ph (9)
Chronic Dialysis Clinics path bil (19)
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8. Office Consultations May Be Conducted at Urgent Care Facilities

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) consultation codes 99241 – 99245 (office evaluation).

An Erroneous Payment Correction (EPC) will be implemented to reprocess select 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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9. ESRD Pilot Project Extended for VillageHealth

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2020. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Pilot Project was established to accept and process claims for participating providers who meet the criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage plan. VillageHealth is the only Medicare Advantage plan for which its providers meet the criteria for Medi-Cal secondary payments.

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
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
oth hlth (1)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
dial end (5); oth hlth (1)
Part 1 mcp spec (7); medicare (3)
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10. Microbiology Procedure Code Policy Updates

Effective for dates of service on or after November 1, 2019, do not report (DNR) audits for microbiology procedure codes 87260-87899 are removed.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
General Medicine
Obstetrics
Family PACT
path micro (5)
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11. Medi-Cal Celebrates Medi-Cal Subscription Service Milestone Achievement

The Department of Health Care Services (DHCS) is excited to announce that its Medi-Cal Subscription Service (MCSS) reached and surpassed 20,000 total subscribers as of September 2019.

DHCS first launched its new MCSS in December of 2012, and since that launch, it has witnessed steady growth each year in the volumes of providers and stakeholders who have joined up and officially subscribed to this free and tailored information-based notification service.

Since launching in 2012, DHCS has marketed its MCSS via informational flyers, online articles and at annual Provider Training Seminars throughout California. It’s at these seminars where MCSS representatives directly informed and assisted providers in signing up for the MCSS at the MCSS information booth.

DHCS has received an impressive array of positive and encouraging feedback from countless providers about the MCSS including their individual and satisfied experiences with this service each year.

The MCSS offers an array of provider communication notifications that subscribers can choose to receive including NewsFlash articles, Medi-Cal Update Bulletins and System Status Alerts (SSAs). In addition, each subscriber is able to tailor their individual MCSS experience by selecting only the provider communications and subject matters that interest them and pertain to their Medi-Cal business.

MCSS is a terrific way for providers and stakeholders to save time and ensure that they never miss important program updates and policy changes. The MCSS notifies subscribers the same day whenever the Medi-Cal program releases articles, bulletins and SSAs on the Medi-Cal website.

Providers who have not yet subscribed to the MCSS are encouraged to join this growing community of more than 20,000 subscribers and take full advantage of this free informational service. DHCS invites providers and other interested parties to subscribe today by completing the MCSS Subscriber Form located online.

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12. 2019 Immunization Updates: Flu, HepA, HPV, Measles, CA School Requirements

A new DUR Educational Article titled “2019 Immunization Updates: Flu, HepA, HPV, Measles, CA School Requirements” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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13. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs 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
August 5, 2019 DAROLUTAMIDE Drug added, administration added, restrictions added drugs cdl p1a (56)
October 1, 2019 TINIDAZOLE Drug added, administration added drugs cdl p1d (19)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2019 AZITHROMYCIN Restrictions removed drugs cdl p1a (20)
October 1, 2019 CEFIXIME Restrictions removed drugs cdl p1a (36)
October 1, 2019 COLCHICINE Restriction changed drugs cdl p1a (50)
October 1, 2019 SOFOSBUVIR/
VELPATASVIR
Restrictions changed drugs cdl p1d (5)

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14. Authorized Drug Manufacturer Labeler Codes Update

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

Additions, effective October 1, 2019
NDC Labeler Code Contracting Company's Name
14539 HERITAGE PHARMA LABS, INC.
42658 HISUN PHARMACEUTICALS USA, INC.
69230 CAMBER CONSUMER CARE INC.
70382 OCULAR THERAPEUTIX, INC.
71376 IRONSHORE PHARMACEUTICALS, INC.
71894 AVEXIS INC.
72124 CIRCASSIA PHARMACEUTICALS INC.
72152 SAGE THERAPEUTICS
72237 KARYOPHARM THERAPEUTICS
72305 PROVELL PHARMACEUTICALS, LLC.
72578 VIONA PHARMACEUTICALS INC.
72606 CELLTRION USA, INC.
72912 ADLON THERAPEUTICS L.P.
   
Changes, effective October 1, 2019
NDC Labeler Code Contracting Company's Name
59467 HIKMA SPECIALTY USA INC.
   
Terminations, effective October 1, 2019
NDC Labeler Code Contracting Company's Name
13551 FSC LABORATORIES, INC.
61894 SYMPLMED PHARMACEUTICALS
69536 FOUNDATION CONSUMER HEALTHCARE, LLC
69916 TRIBUTE PHARMACEUTICALS US, INC.
69973 HALTON LABORATORIES

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 (6–8, 13, 18–21)
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15. 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 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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16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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