Medi-Cal Update

Obstetrics | March 2020 | Bulletin 549

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1. The Medi-Cal Learning Portal Will Soon Be Upgraded

The Medi-Cal Learning Portal (MLP) will soon be upgraded and users will experience a new look, feel and navigational changes. The MLP is hosted using a commercial off-the-shelf software application that automates the administration, tracking and reporting of training events. The MLP publishes training material and curriculum on the internet and manages the training programs for the provider and billing communities.

The functions of the upgraded MLP are easy to navigate, and users will have logical, straight-forward access to much of what they need. The new MLP enables a blended approach to learning, combining classroom delivery, business and technical workshops, virtual classrooms, e-learning and one-on-one mentoring.

The refreshed Medi-Cal Learning Portal page will continue to be accessible from either its original location or from the Outreach & Education page of the Medi-Cal website. There will be no changes to how users will reach the upgraded MLP.

With some of the new or improved features, users will be able to:

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2. Every Woman Counts Income Eligibility Guidelines Update

Effective April 1, 2020, through March 31, 2021, Every Woman Counts (EWC) providers are to use the following income guidelines when determining recipient eligibility for EWC. Providers should disregard all previous income eligibility guideline charts.

EWC recipients must have a household income at or below 200 percent of the federal Health and Human Services (HHS) poverty guidelines. The HHS poverty guidelines are adjusted annually. “Gross household income” means income before taxes and other deductions.

EWC Income Eligibility Guidelines
200 Percent of the 2020 HHS Poverty Guidelines by Household Size Effective April 1, 2020, through March 31, 2021
Number of Persons Living in Household Monthly Gross Household Income Annual Gross Household Income
1 $2,127 $25,520
2 $2,873 $34,480
3 $3,620 $43,440
4 $4,367 $52,400
5 $5,113 $61,360
6 $5,860 $70,320
7 $6,607 $79,280
8 $7,353 $88,240
For each additional person, add: $747 $8,960

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (11)
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3. Electronic SAR Now Supports Attachments

The California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) providers can now submit Service Authorization Requests (SARs) in an electronic format (eSARs) with attachments. Attachments must be in format of PDF, JPG or TIF. Attachments must be less than 15 megabytes (MB) in size, with the sum of all attachments being less than 150 MB. This feature aims to eliminate the paper SAR process for providers with internet connectivity.

To submit eSARs, providers must:

Then, select one of the available options to submit:

  1. Utilize the enhanced online fillable form of the PEDI system to submit eSARs with the attachment

  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 275/278 transactions

    • Simple Object Access Protocol (SOAP)/Hypertext Transfer Protocol Secure (HTTPS) secure web services method to transmit and receive ASC X12 275/278 transactions

Registered providers and clearinghouses 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 practical reasons to do so.

Providers interested in learning more about eSAR submissions 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
Hospice Care Program
Inpatient Service
Local Educational Agency
Obstetrics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (12)
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4. Place of Service Code 25 (Birthing Center) Updates

Effective for dates of service on or after April 1, 2020, Place of Service code 25 (birthing center) is not reimbursable in connection with Evaluation and Management (E&M) CPT® codes 99221 – 99233, 99238 and 99239 (hospital services). Place of Service code 25 is reimbursable in connection with E&M codes 99234 – 99236 (observation hospital, same day).

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (8)
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5. Rate Update for Fetal Aneuploidy

Effective retroactively for dates of service on or after July 1, 2019, Medi-Cal has updated the reimbursement rate for CPT® code 81507 (Fetal aneuploidy [trisomy 21, 18, and 13] DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy). The Medi-Cal reimbursement rate for CPT code 81507 is $636.

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

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6. Erroneously Denied Claims for Contraceptive Ring and Patch

The Department of Health Care Services identified claims for HCPCS codes J7303 (contraceptive supply, hormone containing vaginal ring, each) and J7304 (contraceptive supply, hormone containing patch, each) that were erroneously denied with Remittance Advice Details (RAD) code 9942: NCCI (National Correct Coding Initiative) quantity billed greater than allowed MUE (Medically Unlikely Edit) quantity.

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims that were erroneously denied for dates of service on or after January 1, 2019. No action is required of providers.

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7. Split-Billed Radiology Services Reimbursement Rate Adjustment

Effective retroactively for dates of service on or after April 1, 2017, reimbursement rates for split-billed radiology services will be adjusted to align with Medicare’s 2017 split-billed updates.

The rates adjustment will be implemented on March 23, 2020, but will not appear on the Medi-Cal rates website until April 16, 2020.

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

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8. Removal of Erroneous Language for Select Molecular Pathology Procedures

Effective for dates of service on or after April 1, 2020, claims with approved Treatment Authorization Requirements (TARs) for CPT® codes 81400-81407 (molecular pathology procedure, Levels 1-8) do not require redocumentation of TAR criteria on claims submission.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (33, 35, 36, 38, 41)
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9. New Provider Web Page Coming Soon to the New Medi-Cal Provider Website

The Department of Health Care Services (DHCS) will launch a New Provider web page with the upcoming release of its new Medi-Cal Provider website.

This new web page will offer an organized location for critical information, helpful documents and charts, as well as key links that a “new provider” will need to ensure a successful setup and future as a provider within the Medi-Cal program.

The “New Provider” web page will include information on the following critical Medi-Cal subjects:

DHCS projects a spring 2020 launch. It is recommended that providers continually check the current Medi-Cal website for updates. Providers are also encouraged to subscribe to the convenient and free Medi-Cal Subscription Service (MCSS) to ensure they receive the latest policy news and program updates immediately and regularly.

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10. New Web Page for CHDP Providers

Child Health and Disability Prevention (CHDP) program providers can now find CHDP program policy, billing, reference and user guide content on the “EPSDT/CHDP ” web page. Outdated information on the former “CHDP Provider Manual and Bulletin” web page on the Medi-Cal website was removed, and the current CHDP program information incorporated into the Medi-Cal provider manual.

Providers are encouraged to view the updated Medi-Cal web page and become familiar with the layout, links and revised sets of Frequently Asked Questions (FAQs).

The CHDP program facilitates the early and periodic screening components of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for children and youth enrolled in the Medi-Cal fee-for-service health care delivery system. The EPSDT benefit provides comprehensive health coverage for all children under age 21 who are enrolled in Medicaid. Created in 1967 and required by the federal government in every state with Medicaid, EPSDT finances a wide array of preventive and medically necessary pediatric services. EPSDT/CHDP information is integrated into the following Medi-Cal provider manual sections:

EPSDT/CHDP
EPSDT/CHDP: Gateway
EPSDT/CHDP: School-Based Services

Reminder
Effective November 2019, the information formerly published in the separate CHDP provider manual is incorporated into the Medi-Cal Provider Manual in the three new sections listed above. The former CHDP manual contained old billing instructions, including the use of a two-character procedure code on the Confidential Screening/Billing Report (PM 160) claim form, a form no longer in use. Now, CHDP providers bill services directly to Medi-Cal in accordance with HIPAA national standards and instructions contained in the Medi-Cal provider manual.

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11. May 2020 Medi-Cal Provider Seminar

The May Medi-Cal provider seminar is scheduled for May 12, 2020, at the Red Lion Hotel in Redding, 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 MMIS Fiscal Intermediary 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 April 24, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After April 24, 2020, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks 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. To contact the regional representative for your area, 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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12. 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.

Effective Date Drug Summary of Changes Page(s) Updated
January 2, 2020 FAM-TRASTUZUMAB
DERUXTECAN-NXKI
Drug added drugs cdl p1b (16)
      drugs cdl p4 (8)
April 1, 2020 APIXABAN Drug added drugs cdl p1a (15)
      drugs cdl p4 (10)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
March 1, 2020 ULIPRISTAL ACETATE Restriction added drugs cdl p1d (27)
April 1, 2020 AMPHETAMINE, MIXED SALTS (AMPHETAMINE SULFATE,
AMPHETAMINE
ASPARTATE MONOHYDRATE,
DEXTROAMPHET-AMINE SULFATE AND DEXTROAMPHET-AMINE SACCHARATE)
Restriction removed drugs cdl p1a (13)
April 1, 2020 LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE Restriction added drugs cdl p1b (50)
April 1, 2020 METHYLPHENIDATE HCL Restriction added drugs cdl p1b (71)
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13. Reminder: Screening for Adverse Childhood Experiences Is a Medi-Cal Benefit

Effective for dates of service on or after January 1, 2020, screening for Adverse Childhood Experiences (ACEs) is a Medi-Cal benefit. Medi-Cal reimburses for ACEs screenings for both children and adults up to 65 years of age, except for those dually eligible for Medi-Cal and Medicare Part B, with California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) funds. Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services – Memorandum of Agreement (IHS-MOA) 638, Clinics will also be able to receive these reimbursements, in addition to their Prospective Payment System (PPS) and all-inclusive per-visit reimbursement.

Individuals under 21 years of age may receive periodic rescreening as determined appropriate and medically necessary, but screenings will not be reimbursed more than once per year, per provider. Screenings for individuals 21 years of age or older will not be reimbursed more than once in their lifetime, per provider. The required screening tool for use by providers is the top portion of the Pediatric ACEs and Related Life-events Screener (PEARLS) for individuals under 18 years of age and the ACEs questionnaire for individuals 20 years of age or older. For individuals 18 or 19 years of age, either tool may be utilized. If an alternative version of the ACEs questionnaire for individuals 20 years of age or older is used, it must contain questions on the 10 original categories of ACEs to qualify.

ACEs screenings will be reimbursed in both the fee-for-service Medi-Cal program and Managed Care Plans (MCPs) when billed with either of the two HCPCS codes below:

These codes may be billed to Medi-Cal directly even if the recipient has Other Health Coverage (OHC).

For fee-for-service Medi-Cal providers, screenings for ACEs are reimbursed at the Medi-Cal rate up to $29. For Medi-Cal MCPs, screenings for ACEs are reimbursed no less than $29 for each qualifying ACEs screening. Billing requires that the completed screening was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the recipient and/or family and any clinically appropriate actions were documented. This documentation should remain in the recipient’s medical record and be available upon request. The Department of Health Care Services (DHCS) will release additional information in a future announcement about how FQHCs, RHCs and IHS-MOA clinics can bill for trauma screening.

In order to be eligible for the trauma screening reimbursement after July 1, 2020, providers must complete the DHCS training for ACEs screening and trauma-informed care. In December 2019, DHCS launched www.ACEsAware.org, which includes information about DHCS’ provider training and other resources.

For more information, providers may visit the DHCS Trauma Screenings and Trauma-Informed Care Provider Trainings page of the DHCS website.

An Erroneous Payment Correction (EPC) will be implemented to reprocess any claims erroneously denied for dates of service on or after January 1, 2020. Providers should continue to bill their claims timely and check for updates on the Medi-Cal website.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
General Medicine
Medical Transportation
Obstetrics
oth hlth cpt (4)
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14. Medical Supply Billing Codes Are Not Yet Updated to DME Supply Billing Codes

A previously published Medi-Cal Update article titled “Policy for Medical Supply Billing Codes Updated to DME Supply Billing Codes” notified providers that, effective for dates of service on or after February 1, 2020, certain medical supply billing codes are updated to Durable Medical Equipment (DME) supply billing codes, certain DME codes are added and certain medical supply codes policy is changed. The policy from that article will not be implemented at this time, including policy regarding benefit status and billing requirements. All updates that were made to reflect this policy are removed from the Medi-Cal provider manuals. Until further notice, providers should continue to bill the codes in this policy as medical supply codes and should not bill these items as DME supply codes.

HCPCS Code Description
A4230 Infusion set for external insulin pump, non needle cannula type
A4231 Infusion set for external insulin pump, needle type
A4232 Syringe with needle for external insulin pump, sterile, 3 cc
A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation
A7002 Tubing, used with suction pump, each
A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
A7004 Small volume nonfiltered pneumatic nebulizer, disposable
A7006 Administration set, with small volume filtered pneumatic nebulizer
A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor
A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor
A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 ft
A7012 Water collection device, used with large volume nebulizer
A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator
A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer
B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape
S8186 Swivel adaptor

Until further notice, medical supplies HCPCS code A4223 (infusion supplies not used with external infusion pump, per cassette or bag) continues to be reimbursable for infusion supplies with or without an infusion pump. HCPCS code A4222 (infusion supplies for external drug infusion pump, per cassette or bag) is not yet reimbursable as a DME supply.

Until further notice, the following HCPCS codes are not yet reimbursable:

HCPCS Code Description
A4224 Supplies for maintenance of insulin infusion catheter, per week
A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer

Until further notice, the following medical supplies codes are no longer end-dated and continue to be reimbursable:

HCPCS Code Description
B9998 Extension set for enteral feeding
B9999 Infusion supplies not otherwise classified
S1015 IV tubing extension set

Providers are encouraged to check the Medi-Cal website regularly for updates.

Updated manual pages and the updated Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet reflecting this change will be released in a future Medi-Cal Update.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (1)
Audiology and Hearing Aids medi non hcp (1); tax (6–8, 10, 12, 14)
Durable Medical Equipment dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); tax (6–8, 10, 12, 14)
General Medicine
Obstetrics
Clinics and Hospitals
medi non hcp (1); presum bill (12)
Orthotics and Prosthetics dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1); tax (6–8, 10, 12, 14)
Pharmacy dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); presum bill (12); tax (6–8, 10, 12, 14)
Therapies dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1)
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15. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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