Medi-Cal Update

Pharmacy | June 2012 | Bulletin 777

Print Medi-Cal Update
 

1. Reminder: Durable Medical Equipment Reimbursement Limitation

Providers are reminded that according to Title 22, California Code of Regulations, Section 51321(g), authorization for Durable Medical Equipment shall be limited to the lowest cost item that meets a patient’s medical needs.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Chiropractic
General Medicine
Obstetrics
Pharmacy
Psychological Services
cms spec (7)
Audiology and Hearing Aids
Orthotics and Prosthetics
cms spec (7); spe dev (1)
Durable Medical Equipment and Medical Supplies
Therapies
cms spec (7); spe dev (1); tar dis cod (1)
Medical Transportation cms spec (7); tar dis cod (1)
Inpatient Services tar dis cod (1)
Adult Day Healthcare Centers
Clinics and Hospitals
Rehabilitation Clinics
spe dev (1); ub spec op (6)
AIDS Waiver Program
Chronic Dialysis Clinics
Expanded Access to Primary Care Program
Heroin Detoxification
Hospice Care Program
Local Educational Agency
Multipurpose Senior Services Program
ub spec op (6)
Home Health Agencies/Home and Community-Based Services
tar dis cod (1); ub spec op (6)
Print Article | Return to Top
 

2. July 2012 Medi-Cal Provider Seminar

Throughout the year, the Department of Health Care Services (DHCS) and the Fiscal Intermediary for Medi-Cal, Affiliated Computer Services (ACS), will conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, will cover the following topics:

The next seminar is scheduled for July 17, 2012, at the Red Lion Hotel in Redding, California. Providers can access a class schedule and RSVP for the seminars by visiting the Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar dates that they would like to attend.

Providers are encouraged to bookmark the Training page and refer to it often for current seminar information.

Providers may also schedule a custom billing workshop by contacting their Regional Representative in one of the following ways:

Print Article | Return to Top
 

3. CMC Billing and Technical Manual Update

Background
The Department of Health Care Services (DHCS) has released the National Council for Prescription Drug Programs (NCPDP) D.0 Transaction Companion Guide, known as the NCPDP Standard Payer Sheet. The NCPDP Standard Payer Sheet is currently a draft document as explained below. The targeted date for Medi-Cal’s implementation of the D.0 standard is June 25, 2012. Once implemented, submitters will be required to test and certify with Medi-Cal on the D.0/1.2 transaction prior to submitting in that format.

NCPDP Version D.0 (vD.0)
The NCPDP Payer Sheet for the vD.0 transaction is released as a draft document due to the delay of the Prior Authorization transaction. Once details are confirmed, the NCPDP Standard Payer Sheet will be revised to include the Prior Authorization transaction and will be released as a final version.

CMC Billing and Technical Manual Update
The Computer Media Claims (CMC) Billing and Technical Manual is being updated on an ongoing basis to reflect the new HIPAA 5010 and NCPDP D.0/1.2 formats. The updated sections will be posted under the “5010 CMC Billing and Technical Manual” heading on the CMC Billing and Technical Manual page. The following sections have been updated:

Related Information and Resources

Print Article | Return to Top
 

4. Belatacept a New Medi-Cal Benefit

Effective for dates of service on or after July 1, 2012, HCPCS code C9286 (injection, belatacept, 1 mg) is a new Medi-Cal benefit. Belatacept will be reimbursed using HCPCS code C9286 in conjunction with
ICD-9-CM code V42.0 (Kidney transplant). Use is restricted to patients 19 years of age and older.

Belatacept is indicated for prophylaxis of organ rejection in adult patients receiving a kidney transplant. Belatacept is to be used in combination with basiliximab induction, mycophenolate mofetil and corticosteroids.

The recommended dosing schedule is as follows:

Dosage for Initial Phase Dose
Day 1 (day of transplantation, prior to implantation) and Day 5 (approximately 96 hours after Day 1 dose) 10 mg per kg
End of Week 2 and Week 4 after transplantation 10 mg per kg
End of Week 8 and Week 12 after transplantation 10 mg per kg

Dosage for Maintenance Phase Dose
End of Week 16 after transplantation and every 4 Weeks (plus or minus 3 days) thereafter 5 mg per kg

The maximum recommended dose is 1,300 mg (1.3 Grams) per day. An override of the maximum dose and ICD-9-CM restriction is allowed with an approved TAR.

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 cd list (3); inject drug a-l (6)
Print Article | Return to Top
 

5. Enteral Nutrition Products Sections Revised for Easier Use

The Part 2 manual section formerly named Enteral Nutrition:  List of Available Products has been reorganized to better serve the needs of providers. Enteral nutrition information is now available in the following six sections:

For general policy and billing instructions, consult the Enteral Nutrition Products:  An Overview section of the Part 2 manual. More specific policy, billing instructions and a comprehensive list of products and pricing are available in the respective sections.

These new sections provide clarification to existing policy for easier use. Providers who maintain their own provider manual files should remove the discontinued sections and replace them with the new sections listed above.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (1–9); enteral element (1–8); enteral meta (1–34); enteral spec (1–4); enteral spec infant (1–16); enteral standard (1–19)
Print Article | Return to Top
 

6. New Injection Drugs Established as Medi-Cal Benefits

Effective for dates of service on or after May 1, 2012, the following HCPCS codes will be established as Medi-Cal benefits:

HCPCS Code Description Maximum Dosage
J1650 Injection, enoxaparin sodium, 10 mg 280 mg/day
J2060 Injection, lorazepam, 2 mg 24 mg/day
J2765 Injection, metoclopramide HCl, up to 10 mg 140 mg/day
J2780 Injection, ranitidine hydrochloride, 25 mg 75 mg/day
J3360 Injection, diazepam, up to 5 mg 75 mg/day

Additionally, effective May 1, 2012, HCPCS code X6064 will convert to J3360 and will be terminated.

Providers may increase the administration of each drug beyond the allowable maximum dosage with a Treatment Authorization Request (TAR).

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 cd list (6–7, 11–12, 16, 18)
Print Article | Return to Top
 

7. June Medi-Cal Webinars

Beginning June 5, 2012, and continuing throughout the month of June, Affiliated Computer Services (ACS), the Department of Health Care Services (DHCS) Fiscal Intermediary for Medi-Cal, invites you to participate in Medi-Cal provider training webinars.

The webinars will be as follows:

You will also have the ability to print class materials and ask questions during the training sessions. All recorded webinars will be archived in the Medi-Cal Learning Portal. If you are unable to attend a webinar, you can view it at a more convenient time.

To view the training webinars, you must have Internet access and create your user profile in the Medi-Cal Learning Portal. For more detailed instructions about the registration process and how to access webinar classes, please visit the Outreach & Education page of the Medi-Cal website.

Join us online and take advantage of this exciting opportunity from Medi-Cal.
Print Article | Return to Top
 

8. Drug Utilization Review Board Vacancies

The Department of Health Care Services (DHCS) has announced three volunteer vacancies on the Drug Utilization Review (DUR) board. Members of the DUR board have the opportunity to:

Pharmacists and physicians interested in serving on this important committee can find more information and application instructions on the new DUR: Board Vacancies page of the Medi-Cal website. The deadline for submitting resumes and/or curriculum vitae for consideration is June 30, 2012.

Print Article | Return to Top
 

9. Provider Manuals Updated with HIPAA 5010 Information

The Medi-Cal provider manual has been updated with HIPAA ASC X12N 5010 transaction information. These updates replace previous 4010A1 transaction information and instructions.

Primary updates on the manual pages are as follows:

One exception to the preceding occurred in the Part 1 Medi-Cal provider manual, CMC Enrollment section, page three. The information on that page was deemed more complex and is therefore captured below:

4010 text was: New 5010 text is:
Professional version (claim types 05 and 07) 004010X098A1 Professional version (claim types 05 and 07) 005010X222A1
Institutional version (claim types 02, 03 and 04) 005010X096A1 Institutional version (claim types 02, 03 and 04) 005010X223A2

Beginning June 25, 2012, the new HIPAA 5010 transaction standards will be implemented. Providers who have successfully submitted 5010 test transactions must communicate the date they would like to be activated to submit 5010 transactions with the Telephone Service Center. Activation will begin no sooner than June 25, 2012. Upon a provider’s successful activation for submission of a 5010 transaction submission, the provider may no longer submit using the 4010A1 transaction standard. An end date for processing 4010 transactions has not yet been determined.

Submitters:

Provider manuals will be updated with 5010 transaction information about a week before 5010 transactions will be accepted into production. Providers should note that the claims processing system cannot accept 5010 transactions into production until June 25, 2012.

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

Provider Manual(s) Page(s) Updated
Part 1 cmc (2, 3); cmc enroll (3, 7); cmc enroll check (1); elect (1)
Adult Day Health Care Centers oth hlth (8); opt ben exc (5, 15); ub sub (2, 5, 6)
Acupuncture
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment and Medical Supplies
Medical Transportation
Psychological Services
Therapies
cms comp (1); cms sub (2, 5, 6); opt ben exc (5, 15); oth hlth (8)
General Medicine
Obstetrics
cms comp (1); cms sub (2, 5, 6); opt ben exc (5, 15); oth hlth (8)
Clinics and Hospitals
Inpatient Services
Rehabilitation Clinics
opt ben exc (5, 15); oth hlth (8); ub sub (2, 5, 6)
Long Term Care opt ben exc (5, 15); oth hlth (8); pay ltc comp (12); pay ltc sub (2, 5, 6)
Orthotics and Prosthetics cms comp (1); oth hlth (8)
Vision Care cms comp vc (1); cms sub (2, 5, 6); opt ben exc (5, 15); oth hlth (8)
AIDS Waiver Program
Chronic Dialysis Clinics
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Local Educational Agency
Multipurpose Senior Services Program
ub sub (2, 5, 6); oth hlth (8)
Pharmacy cms comp (1); cms sub (2, 5, 6); compound comp (1, 3, 8); iv sol spec (3, 4); medi cr ph (4); opt ben exc (5, 15); oth hlth (8); pcf 30-1 comp (1, 3, 11); pcf 30-1 spec (2); reject cd pos (1)
Print Article | Return to Top
 

10. Centruroides (Scorpion) Injection is a New Benefit

Effective for dates of service on or after July 1, 2012, Centruroides (scorpion) immune f(ab)2 (equine), 1 vial, is a new Medi-Cal benefit and is billed with HCPCS code C9288. Centruroides (scorpion) immune f(ab)2 (equine) is an anti-venin for scorpion stings. One unit is one vial and routine treatment recommends the intravenous administration of three vials initially and more if needed. An override of the maximum dose is allowed with an approved Treatment Authorization Request (TAR).

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 cd list (4)
Print Article | Return to Top
 

11. Multiple PAD Code Conversions

Effective for dates of service on or after July 1, 2012, the following physician administered drugs (PADs) local codes will be converted to HCPCS codes:

Terminated Local Codes New HCPCS code Maximum Dose
X5924, X5926, X5928 (Chloroprocaine HCL) J2400 60 ml (2 units) per day
X6220 (Fluphenazine Decanoate) J2680 100 mg (up to 4 units) weekly
X6614, X6616 (Naloxone HCL) J2310 12 mg (12 units) per day
X6506, X6754 (Phenobarbital Sodium) J2560 400 mg (4 units) per day
X6236, X6742 (Promethazine HCL) J2550 100 mg (2 units) per day

An approved Treatment Authorization Request will override maximum doses if needed. Physicians are reminded to bill with the appropriate modifier when billing.

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 cd list (4, 8, 10, 11, 13–16, 19)
Print Article | Return to Top
 

12. Incontinence Contracted Product Updates

The Department of Health Care Services (DHCS) recently updated Maximum Acquisition Cost (MAC) contracts with Dependable Incontinence Supply for incontinence supplies in the disposable briefs category. Changes include product additions, effective for dates of service on or after July 1, 2012.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
incont prod brief (5, 9, 12)
Print Article | Return to Top
 

13. Payment Adjustment for Provider-Preventable Conditions

The Department of Health Care Services (DHCS) anticipates approval of a State Plan Amendment (SPA) to adjust payment for Provider-Preventable Conditions (PPC). This will require providers to report PPCs beginning July 1, 2012 and affects all providers of medical care in inpatient and outpatient settings.

Medi-Cal will adjust payment for PPCs, as required by the Affordable Care Act (ACA), section 2702, and as defined by Title 42 of the Code of Federal Regulations, parts 447, 434 and 438. Medi-Cal will not adjust payment for PPC-related claims when the provider notes that the PPC existed prior to the provider initiating treatment for the patient. Payment adjustment shall be limited to PPCs that would otherwise result in an increase in payment and to the extent that DHCS can reasonably isolate for non-payment the portion of payment directly related to the PPC.

If a Medicare crossover claim has a PPC that was not present prior to the provider’s treatment of the patient, DHCS will exclude the PPC from the payment calculation when it can confirm the increased costs are directly attributed to the PPC.

Providers must report the occurrence of any PPCs in any Medi-Cal patient that did not exist prior to the provider initiating treatment. Providers shall report to DHCS regardless of whether or not the provider seeks Medi-Cal reimbursement for services to treat the PPC. They will report PPCs by filling out and sending a one-page form to the DHCS Audits and Investigations Divisions, which is scheduled to be available by July 1, 2012 on the Medi-Cal PPC page on the DHCS website. The forms must be sent to DHCS within five days of the discovery of the PPC and confirmation that the patient is a Medi-Cal recipient.

PPCs, as defined in federal regulations, are Other Provider-Preventable Conditions (OPPC) in all health care settings and Health Care-Acquired Conditions (HCAC) in inpatient hospital settings only.

*

These conditions are further defined for the pediatric population. Definitions are provided in the instructions for reporting.

Print Article | Return to Top
 

14. CMC Error Codes and Messages

The Computer Media Claims (CMC) Billing and Technical Manual is being updated on an ongoing basis to reflect the new HIPAA 5010 and NCPDP D.0/1.2 formats. The updated sections will be posted under the “5010 CMC Billing and Technical Manual” heading on the CMC Billing and Technical Manual page. Providers can view the updated sections by clicking on the manual heading. Submitters must successfully test the new ASC X12N 5010 and NCPDP D.0/1.2 formats before sending transactions in production to Medi-Cal.

The CMC Error Codes and Messages section has been updated to capture the new error codes resulting from HIPAA regulations and is now available. Changes to other sections of the CMC manual are forthcoming.

Providers with questions regarding HIPAA 5010 implementation can call the Telephone Service Center (TSC) at 1-800-541-5555 and choose the appropriate option for language (English or Spanish), option 1 for provider, option 4 for the Technical Help Desk, option 2 for CMC/HIPAA, option 1 for provider or option 2 for submitter and follow the prompts to enter your provider ID, NPI, or submitter ID, followed by option 4 for HIPAA.

Print Article | Return to Top
 

15. Synvisc Reimbursement Update

Some prior claims submitted for HCPCS code J7322 (hyaluronan or derivative, Synvisc, for intra-articular injection, per dose) with dates of service between April 1, 2009 and December 31, 2009, were erroneously denied payment. Claims that were not compensated correctly during that time period will be identified and reprocessed. Providers do not need to take any action.

Print Article | Return to Top
 

16. Age Range Correction for Selective ICD-9-CM Codes

Policy for some diagnosis codes has been updated to align with the four age categories for diagnoses found in the Fiscal Year 2011 “Definitions of Medicare Code Edits.” For dates of service on or after June 25, 2012, the minimum and maximum adult age range for the following ICD-9-CM codes is updated from “21 – 99” to “15 – 124”:

Providers should begin billing with the appropriate diagnosis code listed above for the updated age ranges, starting with dates of service June 25, 2012 forward.

Print Article | Return to Top
 

17. Policy Update for Epinephrine

Effective retroactively for dates of service on or after December 31, 2011, HCPCS code J0171 (injection, adrenalin, epinephrine, 0.1 mg) is reimbursable for all Medi-Cal eligible recipients. Previously the code was only reimbursable for Medicare/Medi-Cal recipients. A Treatment Authorization Request will override higher dosages, if needed.

Print Article | Return to Top
 

18. Policy Change for RHo(D) Immune Globulin 100 IU for Intravenous Injection

Effective retroactively for dates of service on or after March 7, 2011, the maximum dosage for HCPCS code J2792 (injection, Rho(D) immune globulin, intravenous, human, solvent detergent, 100 IU) has been increased to 400 units per day, as needed.

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

Print Article | Return to Top
 

19. Updates to Negative Pressure Wound Therapy Policy

Effective for dates of service on or after July 1, 2012, documentation requirements have been added for the reimbursement of Negative Pressure Wound Therapy (NPWT) devices that are typically used after other appropriate wound treatment modalities have failed to heal skin wounds or ulcers. In addition, the initial and continued authorization of NPWT has been reduced from 30 to 15 days.  

Providers may refer to the appropriate Part 2 provider manual for additional information.

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

Provider Manual(s) Page(s) Updated
General Medicine
Clinics and Hospitals
Inpatient Services
medne (11–12)
Durable Medical Equipment
Pharmacy
dura bil dme (22–24)
Print Article | Return to Top
 

20. Medical Supply Products: Diabetic Testing Supplies Updates

Effective for dates of service on or after July 1, 2012, there will be an increase to the Maximum Allowable Product Cost (MAPC) for certain products by Roche Diagnostic Corporation.

The current MAPC information is available in the Medical Supply Products: Diabetic Supplies section of the Part 2 provider manual.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup prod dia (14)
Print Article | Return to Top
 

21. Presumptive Eligibility for Pregnant Women Form Update

The Weekly Presumptive Eligibility (PE) for Pregnant Women Enrollment Summary form has been updated and can be found on the forms page of the Medi-Cal website.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (17); presum week summ (1)
Print Article | Return to Top
 

22. Orthopedics Code L3000 (Foot Insert, Removable) Reimbursement Policy Update

Effective for dates of service on or after July 1, 2012, the reimbursement policy for HCPCS code L3000 (foot, insert, removable, molded to patient model; “UCB” type, Berkeley Shell, each) has been updated. The reimbursement rate has been increased from $119.18 to $227.19. Frequency is limited to one in five years.

Providers may refer to the Prescription Referrals section of the Part 2 provider manual for additional information.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
prescript (5)
Durable Medical Equipment
Orthotics and Prosthetics
Therapies
Pharmacy
orthocdfre1 (3); orthocd1 (21)
Print Article | Return to Top
 

23. Limit on Hearing Aid Reimbursement

Effective for dates of service on or after July 1, 2012, Medi-Cal limits the total cost of hearing aid benefit services, including sales tax, to $1,510 per recipient per fiscal year (Welfare and Institutions Code [W&I Code], Section 14131.05). A Treatment Authorization Request (TAR) must be sent to the Sacramento Medi-Cal Field Office.

The following are excluded from the cap:

Replacement of hearing aids that are lost, stolen or irreparably damaged due to circumstance beyond the recipient’s control is not included in the $1,510 maximum benefit cap.

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

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
hear aid (1); hear aid bill (1); hear aid cd (1); hear aid ex (2)
Audiology and Hearing Aids
Durable Medical Equipment
Orthotics and Prosthetics
Pharmacy
tax (3)
Print Article | Return to Top
 

24. Medi-Cal Checkwrite Schedule Updated

Effective July 1, 2012, the checkwrite schedule is updated for fiscal year 2012 – 2013. The schedule reflects warrant release dates and Electronic Fund Transfer (EFT) dates of deposit for the following programs:

Note:

This article and checkwrite schedule is a correction to the newsroom article and checkwrite schedule that posted in the Newsroom area of the Medi-Cal website on June 7, 2012. Due to the national bank holiday on 10/8/12, the previous 10/8/12 EFT Settlement Date has been modified to 10/9/12.

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

Provider Manual(s) Page(s) Updated
Part 1 – Medi-Cal Program and Eligibility check (1)
Print Article | Return to Top
 

25. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Print Article | Return to Top


Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.