Medi-Cal Update

Obstetrics | May 2020 | Bulletin 551

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1. Billing Instructions for PE for COVID-19 Program

The Department of Health Care Services (DHCS) implemented Presumptive Eligibility (PE) for the coronavirus disease (COVID-19) on April 8, 2020. PE COVID-19 is available for individuals with no health insurance or who currently have private insurance that does not cover diagnostic testing, testing-related services, and treatment services, including all medically necessary care as a result of COVID-19, do not qualify for any Medi-Cal programs (with the exception of individuals who have not met their Medi-Cal Share of Cost [SOC] obligation), and are a California resident.

Eligibility for COVID-19 will use Aid Code V2 to determine eligibility for these limited benefits. Aid Code V2 is a limited-scope code that will provide access to COVID-19 diagnostic testing, testing-related services, and treatment services, including all medically necessary care for COVID-19 including laboratory services, and the associated office, clinic or emergency room visits, without regard to immigration status, income or resources. It will have date specific eligibility. A Qualified Provider (QP) will enroll the individual on the date of application and their PE eligibility period will end on the last calendar day of the month in which the 60th day falls from the date of their PE application. This program will utilize existing QP(s) in our current PE programs.

Providers must include ICD-10 diagnosis code U07.1 on all claims for reimbursement of COVID-19 medically necessary care for PE individuals in aid code V2. Claims submitted without this diagnosis code, may not be reimbursed. For more information on ICD-10-CM diagnosis code U07.1, please see the March 26, 2020 NewsFlash article.

For billing related questions, providers may contact the Telephone Service Center (TSC) at 1-800-541-5555. The TSC is available 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers should call (916) 636-1200.

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2. New CPT Codes for COVID-19 Anti-body Testing

Effective for dates of service on or after April 10, 2020, the American Medical Association (AMA) has released specific CPT® codes to report and track COVID-19 antibody testing. The AMA has revised code 86318 (immunoassay for infectious agent antibody[ies], qualitative or semiquantitative, single step method) and established 86328 (immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]) and 86769 (antibody; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]) to provide increased specificity to report serologic laboratory testing. Codes 86328 and 86769 each have a frequency limit of two per day and may not be billed with each other on the same date of service. All three codes have been determined to be Medi-Cal benefits.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics path bil (13)
Clinics and Hospitals
General Medicine
Obstetrics
path bil (13); path micro (10)
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3. Specimen Collection for COVID-19 Now Medi-Cal Benefit

Effective for dates of service on or after March 1, 2020, HCPCS codes G2023 (specimen collect covid-19) and G2024 (spec coll snf/lab covid-19) are now Medi-Cal benefits.

The Centers for Medicare and Medicaid Services established two Level II HCPCS codes G2023 and G2024 for the specimen collection for COVID-19 testing. These codes are billable by clinical diagnostic laboratories.

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4. New HCPCS codes for COVID-19 Diagnosis

Effective for dates of service on or after March 18, 2020, the Centers for Medicare & Medicaid Services (CMS) has released specific HCPCS codes U0003 (SARS Cov-2 COVID-19 Amp prob high throughput) and U0004 (COVID-19 lab test non-CDC high throughput) for the detection of SARS-COV-2 or the diagnosis of the virus that causes the coronavirus disease 2019 (COVID-19).

These codes are:

An EPC letter will be issued for affected claims for codes U0003 and U0004 retroactive to dates of service on or after March 18, 2020.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path micro (10, 11)
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5. Child Health and Disability Program (CHDP) Gateway Flexibilities Due to COVID-19

Due to the ongoing response to coronavirus disease 2019 (COVID-19), the Department of Health Care Services (DHCS) is approving immediate enrollment flexibilities for Presumptive Eligibility (PE) providers to limit potential exposure to COVID-19.

CHDP Gateway
Enrolling Providers can utilize telephonic signatures for CHDP Gateway Applications, noting in the case file “COVID-19 protocol.” If the individual is not at the provider’s office and is not experiencing an urgent health event which requires immediate care, providers should suggest the individual to apply online using the Covered California portal to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative Form for the CHDP Gateway applicant, which allows an individual to act on behalf of the applicant and provide the required information to assist with the enrollment of the applicant in CHDP Gateway coverage, thereby minimizing direct contact with the individual and promoting physical distancing.


Process
In order to accept a telephonic signature, the following procedure must be followed:

Questions concerning CHDP Gateway Flexibilities should be sent to Joel Mojica at Joel.Mojica@dhcs.ca.gov.

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6. Presumptive Eligibility for Pregnant Women (PE4PW) Flexibilities Due to COVID-19

Due to the ongoing response to coronavirus disease 2019 (COVID-19), the Department of Health Care Services (DHCS) is approving immediate enrollment flexibilities for Presumptive Eligibility (PE) Providers to limit potential exposure to COVID-19.

Presumptive Eligibility for Pregnant Women (PE4PW)
Qualified Providers can utilize telephonic signatures for PE4PW applications, noting in the case file “COVID-19 protocol.” If the individual is not at the hospital and is not experiencing an urgent prenatal care health event which requires immediate care, providers should suggest the individual to apply online using the Covered California portal to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative Form for the PE4PW applicant, which allows an individual to act on behalf of the applicant and provide the required information to assist with the enrollment of the individual in PE4PW, thereby minimizing direct contact with the individual and promoting physical distancing.

Process
In order to accept a telephonic signature, the following procedure must be followed:

Questions concerning PE4PW Flexibilities should be sent to PE@dhcs.ca.gov.

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7. Hospital Presumptive Eligibility (HPE) Flexibilities Due to COVID-19

Due to the ongoing response to coronavirus disease 2019 (COVID-19), the Department of Healthcare Services (DHCS) is approving immediate enrollment flexibilities for Presumptive Eligibility (PE) providers to limit potential exposure to COVID-19.

Hospital Presumptive Eligibility (HPE)
Enrolling Providers can utilize telephonic signatures for HPE Applications, noting in the case file “COVID-19 protocol.” If the individual is not at the hospital and is not experiencing an urgent health event which requires immediate care, providers should suggest the individual to apply online using the Covered California portal to establish ongoing eligibility for Medi-Cal or Covered California. Providers may also obtain an Authorized Representative Form for the HPE applicant, which allows an individual to act on behalf of the applicant and provide the required information to assist with the enrollment of the patient in HPE, thereby minimizing direct contact with the patient and promoting physical distancing.

Process
In order to accept a telephonic signature, the following procedure must be followed:

Questions concerning HPE Flexibilities should be sent to DHCSHospitalPE@dhcs.ca.gov.

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8. 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 are 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
January 1, 2020 ZANUBRUTINIB Drug added, administration added, restriction added drugs cdl p1d (34)
drugs cdl p4 (9)
May 1, 2020 CYCLOBENZAPRINE Drug added, administration added drugs cdl p1a (51)
drugs cdl p4 (21)
May 1, 2020 DESVENLAFAXINE SUCCINATE Drug added, administration added drugs cdl p1a (59)
drugs cdl p4 (11)
May 1, 2020 DULAGLUTIDE Drug added, administration added, restriction added drugs cdl p1a (69)
drugs cdl p4 (15)
May 1, 2020 METHOCARBAMOL Drug added, administration added drugs cdl p1b (69)
drugs cdl p4 (21)
May 1, 2020 POTASSIUM BICARBONATE/CITRIC ACID Drug added, administration added, restriction added drugs cdl p1c (35)
drugs cdl p4 (16)
May 1, 2020 POTASSIUM CITRATE Drug added, administration added drugs cdl p1c (36)
drugs cdl p4 (16)
May 1, 2020 SODIUM POLYSTYRENE SULFONATE Drug added, administration added drugs cdl p1d (5)
drugs cdl p4 (20)

May 1, 2020

TIZANIDINE HCL

Drug added, administration added

drugs cdl p1d (20)
drugs cdl p4 (21)

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
April 1, 2020 MEDROXYPROGESTERONE ACETATE Strength added drugs cdl p1b (65)
May 1, 2020 CITALOPRAM HBR Strength added, suspension removed drugs cdl p1a (45)
drugs cdl p4 (11)
May 1, 2020 FLUOXETINE HCL Strength added drugs cdl p1b (21)
May 1, 2020 POTASSIUM CHLORIDE product added, restriction added drugs cdl p1c (36)
May 1, 2020 SEVELAMER HCL restriction removed drugs cdl p1d (2)
July 1, 2020 MOXIFLOXACIN HCL restriction added, labeler code removed drugs cdl p1b (78)
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9. April 2020 HCPCS Quarterly Update: Policy Updates

Effective for dates of service on or after April 1, 2020, the following HCPCS codes are new Medi-Cal benefits: C9053 (injection, crizanlizumab-tmca, 1mg); C9056 (injection, givosiran, 0.5 mg); C9057 (injection, cetirizine hydrochloride, 1 mg); and C9058 (injection, pegfilgrastim-bmez, biosimilar, [ziextenzo] 0.5 mg).

An approved Treatment Authorization Request (TAR) is required for reimbursement for HCPCS codes C9053 and C9056.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12)
Clinics and Hospitals
General Medicine
Obstetrics
chemo drug p-z; inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12); non ph (12)
Pharmacy inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13)
Rehabilitation Clinics inject cd list (4, 7, 13); inject drug a-d (33, 37); inject drug e-h (12, 13); modif used (12); non ph (12)
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10. MRI Breast Screening for Every Woman Counts Program

Effective for dates of service on or after June 1, 2020, the following Magnetic Resonance Imaging (MRI) procedures and MRI-Guided services are reimbursable Every Woman Counts (EWC) program benefits.

CPT® codes 19081 – 19086 are to be used for breast biopsies that include image guidance, placement of a localization device and imaging of specimen.These codes cannot be billed in conjunction with codes 19281 – 19288 for image guidance placement of a localization device without image guided biopsy.

These MRI services are not subject to any authorization or Treatment Authorization Request (TAR) requirements.

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

CPT® Code Definition
10011 Fine needle aspiration biopsy, including MR guidance, first lesion
10012 each additional lesion
19085 Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonance guidance, first lesion
19086 additional lesion
19287 Placement of breast localization device, percutaneous; magnetic resonance guidance; first lesion, including magnetic resonance guide
19288 each additional lesion
77046 Magnetic resonance imaging (MRI), breast, without contrast, unilateral
77047 bilateral
77048 Magnetic resonance imaging (MRI), breast, including computer-aided detection (CAD), without and with contrast material(s), when performed; unilateral
77049 bilateral

Use of modifiers (required and optional) is the same for Medi-Cal and EWC claims.

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

Provider Manual(s) Page(s) Updated

Clinics and Hospitals
General Medicine
Obstetrics

ev woman (21 – 24, 27, 28)
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11. Meningococcal Conjugate Vaccine is a Medi-Cal Benefit

Effective retroactively for dates of service on or after July 1, 2019, CPT code 90619 (Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier [MenACWY-TT] for injection into muscle) is a Medi-Cal benefit.

An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims for CPT code 90619. No action is required of providers.

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12. Split-Bill Modifiers Added for Myocardial Imaging

Effective retroactively for dates of service on or after January 1, 2020, CPT® codes 78429-78434 (positron emission tomography) must be billed 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
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
radi nuc (3, 4)
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13. 2020 Update to CHDP Gateway Income Eligibility Guidelines

Effective January 1, 2020, through December 31, 2020, providers are to use the following income guidelines when determining recipient eligibility for pre-enrollment in Medi-Cal through the Child Health and Disability Prevention (CHDP) Gateway program. Providers should disregard all previous CHDP income eligibility guidelines charts.

Income Eligibility Guidelines
266 Percent of the 2020 Federal Poverty Guidelines
Effective January 1, 2020, through December 31, 2020
(For determinations of CHDP Gateway aid codes 8W and 8X only)
Number of Persons in the Household Monthly Income Annual Income
1 $2,829 $33,942
2 $3,822 $45,859
3 $4,815 $57,776
4 $5,808 $69,692
5 $6,801 $81,609
6 $7,794 $93,526
7 $8,787 $105,443
8 $9,780 $117,360
9 $10,773 $129,276
10 $11,767 $141,193
For households of more than 10 persons, for each additional person, add: $994 $11,917

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Clinics and Hospitals
General Medicine
Obstetrics
Orthotics and Prosthetics
Psychological Services
Vision Care
epsdt chdp gate (11)
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14. 2020 Income Eligibility Guidelines for PE4PW

Effective January 1, 2020 through December 31, 2020, Presumptive Eligibility for Pregnant Women (PE4PW) program providers must use the following income guidelines to make PE4PW determinations. Providers should disregard all previous PE4PW income eligibility guidelines charts.

Federal Poverty Level Chart for PE4PW
Effective January 1, 2020, through December 31, 2020
Number of Persons in Family 213 Percent
Monthly Income
213 Percent
Annual Income
2 $3,061 $36,722
3 $3,856 $46,264
4 $4,651 $55,806
5 $5,446 $65,349
6 $6,241 $74,891
7 $7,037 $84,434
8 $7,832 $93,976
9 $8,627 $103,518
10 $9,422 $113,061
11 $10,217 $122,603
12 $11,013 $132,146
For family units of more than 12 members, for each additional member, add: $796 $9,543

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (4)
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15. Second Update to NCCI Quarterly Update for January 2020

On February 25, 2020, Centers for Medicare and Medicaid Services (CMS) updated payment policy as part of the National Correct Coding Initiative (NCCI) Quarterly Updates for January. The updated payment policy is effective January 1, 2020.

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

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16. July 2020 Medi-Cal Provider Seminar

The July Medi-Cal provider seminar is scheduled for July 29 – 30, 2020, at the California Center for the Arts in Escondido, 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 July 10, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After July 10, 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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17. Medi-Cal Subscription Service Upgrade Coming Soon

The Medi-Cal Subscription Service (MCSS) portal will soon be upgraded with new features added. The new functionality will support increased collaboration between the Medi-Cal Program and Medi-Cal providers and stakeholders. This will allow DHCS to provide the most relevant information to providers electronically and allow providers to engage with the program through discussion groups and multiple communication channels.

Subscribers will continue to be able access the MCSS portal by selecting the link found on the Medi-Cal website splash page. With these new changes, users can expect to be able to:

In addition, the new MCSS portal will enable Medi-Cal to communicate with providers and stakeholders via additional communication channels in the future, such as SMS text, chat and provider community forums.

Provider community forums are a key functionality change, which will allow Medi-Cal to deploy the other types of communication mechanisms as program and business needs arise.

A current example Medi-Cal plans to roll out is the ability for providers and stakeholders to subscribe to threads and receive alerts in the forums to be notified when new posts are added, which will help keep them up to date on important changes.

In the future as needs evolve, Medi-Cal will announce other forum features and capabilities.

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18. Drug Safety Communication: Withdrawal of All Ranitidine Products

A new DUR Educational Article titled “Drug Safety Communication: Withdrawal of All Ranitidine Products” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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19. Quality of Care Update: Risks Associated with Use of Fluoroquinolones

A new DUR Educational Article titled “Improving Quality of Care: Update of Risks Associated with Use of Fluoroquinolones” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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20. 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 April 1, 2020
NDC Labeler Code Contracting Company’s Name
69087 CLARUS THERAPEUTICS, INC.
Terminations, effective April 1, 2020
NDC Labeler Code Contracting Company’s Name
60219 AMNEAL PHARMACEUTICALS
71758 AVADEL SPECIALTY PHARMACEUTICALS LLC
00066 AVENTIS PHARMACEUTICALS
00316 CROWN LABORATORIES, INC.
68774 DAVA PHARMACEUTICALS, INC.
64253 MEDEFIL, INC.
71709 METCURE PHARMACEUTICALS, INC.
61145 REPHARM 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 (2, 4, 5, 9, 13, 15, 17, 18, 20)
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21. 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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22. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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