Medi-Cal Update

Pharmacy | April 2017 | Bulletin 893

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1. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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2. Update: DHCS Fiscal Intermediary Name Change

Effective immediately, providers may notice that the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) for the Medi-Cal program, formerly Xerox State Healthcare, LLC (Xerox), is operating under a new company name, “Conduent.” Providers may also see the Conduent logo on some items.

Operations and interactions with providers are not impacted by this FI name change.

Providers may see this name change in items such as:

  • NewsFlash articles and Medi-Cal Update bulletins
  • Medi-Cal website (www.medi-cal.ca.gov)
  • Forms and User Guides
  • Provider Manuals
  • Medi-Cal Learning Portal (MLP)
  • Presentations at Provider Training Seminars
  • Provider Letters, such as Erroneous Payment Corrections (EPCs)
  • Additional hard copy correspondence
  • Emails with an “@conduent.com” address rather than an “@xerox.com” address
  • References to the Conduent name when researching mailing addresses or published telephone numbers
Conduent logo

There are no changes in the telephone numbers used by providers, including the Telephone Service Center (TSC) number (1-800-541-5555), as a result of this name change. The mailing addresses used by providers to conduct business with DHCS and the FI will remain the same.

Medi-Cal providers are strongly encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to Medi-Cal Update bulletins, NewsFlash articles, and System Status Alerts. Providers may sign up for MCSS by visiting http://www.medi-cal.ca.gov and completing the MCSS Subscriber Form. For more information about Conduent, visit https://www.conduent.com.

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3. Billing Policy Clarifications for End of Life Option Act Services

Beginning May 1, 2017, the billing policy for End of Life Option Act (ELOA) services and aid-in-dying drugs has been clarified as follows:

 
HCPCS Code ICD-10-CM Diagnosis Codes
J7999 Z76.89
J8499 Z76.89
S0257 Z01.89, Z76.89

Additionally, the provider manual has been updated to reflect billing instructions regarding valid unit of measurement qualifiers. Billing examples for CMS-1500 and UB-04 forms have also been updated to reflect these instructions.

These updates are effective retroactively for dates of service on or after June 9, 2016.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Community-Based Services
Durable Medical Equipment
Heroin Detoxification
Home Health Agencies/Home and Hospice Care Program
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Rehabilitation Clinics
Therapies
Vision Care
medi non hcp (2)
Clinics and Hospitals eloa ub (6–11); medi non hcp (2)
General Medicine
Pharmacy
Psychological Services
eloa (7, 9, 11–14); eloa cms (5–11); medi non hcp (2)
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4. CHDP Phase 2: HIPAA Code Conversion and Claim Form Transition

Effective for dates of service on or after July 1, 2017, the two-digit local procedure codes currently used for Child Health and Disability Prevention (CHDP) program claims are discontinued. The codes will be replaced with national HCPCS procedure codes and modifiers that comply with HIPAA requirements.

The CHDP Confidential Screening and Billing Report (PM 160) claim form will no longer be used to bill for CHDP Early and Periodic Screening, Diagnosis and Treatment (EPSDT) health assessments, immunizations and ancillary services for dates of service on or after July 1, 2017. For these dates of service, qualified Medi-Cal providers enrolled in the CHDP program must bill CHDP/EPSDT services on a CMS-1500, UB-04 claim form or electronic equivalent. Providers should note the national codes cannot be submitted on the PM 160.

Code Conversion Table: To view the full code conversion and additional instructions, providers may refer to the CHDP Code Conversion Table. Updated manual sections will be released in future CHDP Update and Medi-Cal Update bulletins.

This is Phase 2 of the CHDP transition to national codes and claim submission methods. Phase 1, which was effective February 1, 2017, was for CHDP providers submitting claims for laboratory-only services. To see what was published for Phase 1, providers may refer to the article CHDP HIPAA Code Conversion for Clinical Laboratory Service Providers Coming Soon.

Facts about both Phase 1 and Phase 2 are available on the CHDP Frequently Asked Questions page of the Medi-Cal website.

Providers are encouraged to watch for CHDP updates in the NewsFlash area on the Medi-Cal website, and subscribe to the Medi-Cal Subscription Service (MCSS) to receive timely notifications related to CHDP by completing the MCSS Subscriber Form. Providers with questions or concerns may call the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, except holidays.

Email Address for Questions/Concerns
Providers may submit questions or concerns regarding the CHDP code conversion and claim form transition to CHDPTransition@conduent.com.

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5. SSN Removal Initiative to Replace HIC Number on Medicare Cards

The Medicare Access and CHIP Reauthorization Act of 2015 requires Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim (HIC) number on new Medicare cards and will be used for transactions such as billing, eligibility status and claim status.

A transition period will allow providers to use either the HIC number or the MBI. The transition will begin no earlier than April 1, 2018, and run through December 31, 2019.

CMS currently uses SSN-based HIC numbers to identify Medicare recipients and have used HIC numbers with state Medicaid agencies, health care providers and health plans. Under the new system, CMS will assign a new MBI and send a new Medicare card for each recipient enrolled in Medicare. The MBI should be protected as Personally Identifiable Information (PII).

Additional resources can be found on the Providers and Health & drug plans Web pages of the CMS website.

Additional information regarding this transition will be announced in a future Medi-Cal Update.

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6. Update to Diagnostic Criteria for Obstructive Sleep Apnea

Effective for dates of service on or after May 1, 2017, the diagnostic criteria for obstructive sleep apnea (OSA) is expanded to reflect separate criteria for patients ages 18 and older, and patients ages 1 through 17. Additionally, coverage for continuous positive airway pressure (CPAP) equipment has been clarified.

These updates reflect guidelines published in the American Academy of Sleep Medicine. International Classification of Sleep Disorders, Third Edition. American Academy of Sleep Medicine, Darien, IL, 2014, and in “American Academy of Pediatrics Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome,” Pediatrics 130, no. 3 (2012): 576-584.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment Pharmacy dura bil oxy (22, 23)
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7. CCS Service Code Groupings Update

The following codes will be added or end-dated to/from the California Children’s Services (CCS) Service Code Groupings (SCGs):

Added Codes:
Effective Date Code SCG
July 1, 2015 CPT-4 codes 80180, 86832, 86833 03
October 1, 2015 HCPCS codes C9444, C9446, C9447, J0153, J0887, J0888, J1439, J2274, J2704, J7336, J9120
CPT-4 codes 62304, 62305, 64486 – 64489, 76641, 76642, 77061 – 77063, 77085, 77086, 80163, 80165, 80300 – 80304, 80320 – 80377, 90630, 93702, 96127, 99490, 99497, 99498
01, 02, 03, 07
October 1, 2015 HCPCS codes A9606, C2624, C9442, G0472, G6001 – G6020, G6022 – G6025, G6027, G6028, J1071, J3121, J3145, J9267, J9301
CPT-4 codes 43180, 44381, 44384, 44401, 44402, 44404 – 44408, 45346, 45347, 45349, 45350, 45388 – 45390, 45393, 45398, 46601, 46607, 77306, 77307,
77316 – 77318, 77385 – 77387, 87623 – 87625, 87806, 88341, 88344, 88364, 88366, 88369, 88373, 88374, 88377, 89337, 91200, 93260, 93261, 93355, 93644, 93895, 99184
02
October 1, 2015 HCPCS codes Q4150 – Q4159
CPT-4 codes 20604, 20606, 20611, 20983,
21811 – 21813, 22510 – 22515, 22858, 27279
07
October 1, 2015 CPT-4 codes 66179, 66184, 92145 10
October 1, 2015 CPT-4 code 20606 12
April 1, 2016 HCPCS codes G0108, G0109
CPT-4 codes
97802 – 97804
01, 02, 03, 07

End-Dated Codes:
Effective Date Code SCG
October 1, 2015 HCPCS codes
G8629 – G8632, G8682, G8683, G8685, J0150, J1070, J1080, J2271, J2275, J3120, J7335, S0144
CPT-4 codes 29715, 72291, 72292, 74291, 76645, 76950, 80102, 80104, 80152, 80154, 80160, 80166, 80172, 80174, 80182, 80196, 82000, 82003, 82055, 82101, 82145, 82205, 82520, 82646, 82649, 82651, 82654, 82666, 82690, 82742, 82953, 82975, 82980, 83008, 83055, 83071, 83634, 83805, 83840, 83858, 83866, 83887, 83925, 84022, 84127, 87001,
87620 – 87622
01, 02, 03, 07
October 1, 2015 HCPCS code J9265
CPT-4 codes 21800, 44383, 44393, 44397, 45339, 45345, 45355, 45383, 45387, 77305, 77310, 77315, 77326 – 77328, 77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416, 77418, 77421
02
October 1, 2015 CPT-4 codes 29020, 29025 07
October 1, 2015 CPT-4 codes J3140 01, 02, 03, 07, 09
October 1, 2015 CPT-4 codes 61334, 66165 10
October 1, 2015 HCPCS codes J0900, J1060
CPT-4 code 88349
01, 02, 03, 07, 12
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 (1–3, 5–17, 20, 23–29, 31)
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8. Eteplirsen Claims Require SAR for CCS and GHPP

Effective retroactively for dates of service on or after September 1, 2016, eteplirsen is added to the pharmacy list of drugs and nutritional products requiring a separate Service Authorization Request (SAR) for the California Children's Services (CCS) program and the Genetically Handicapped Persons Program (GHPP).

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); genetic (9)
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9. Resolved: Non-Home Health Claims Erroneously Denied with RAD Code 0076

A claim processing issue that caused non-Home Health claims to be erroneously denied with Remittance Advice Details (RAD) code 0076: The submitted documentation was not adequate has been resolved.

As a reminder, providers who are not required to record a revenue code on their claims should always leave blank the Revenue Code field (Box 42).

Affected claims will be re-processed by an Erroneous Payment Correction (EPC). No action is required of providers. Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.

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10. PE for Pregnant Women Web Page Revised and New MC 311 Form Posted

Effective March 30, 2017, the Qualified Provider Application and Agreement for Participation in the Presumptive Eligibility for Pregnant Women (PE4PW) Program (MC 311) form has been updated on the Presumptive Eligibility for Pregnant Women Web page of the Medi-Cal website. This form is completed by providers applying to become PE4PW Qualified Providers or once enrolled, when requesting to add to their list of PE4PW clinic(s).

Instructions on completing the form are included with the MC 311 (version 12/16). Providers should review the provider requirements, submission checklist and notification overview when completing the form.

Note:

Providers will submit the form to Telephone Service Center using the address provided on the form. PE4PW providers are encouraged to review the PE4PW Web page’s Frequently Asked Questions (FAQs) and to visit the NewsFlash area of the Medi-Cal website for articles and materials related to the PE4PW program.

The PE4PW Web page has three new headings. “Application Forms” has changed to “Paper Process Forms (usable until 9/30/17).” The new MC 311 form is posted under the new “Qualified Provider Enrollment Form” heading. Lastly, a “User Guide” heading has been added to accommodate the new Presumptive Eligibility for Pregnant Women (PE4PW) Application Web Portal User Guide.

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11. New Presumptive Eligibility for Pregnant Women User Guide

The Presumptive Eligibility for Pregnant Women (PE4PW) Application Web Portal User Guide is now available on the Medi-Cal website. The user guide provides instructions for accessing and performing a PE4PW Web Portal transaction.

Providers may download the user guide and access additional PE4PW Program information on the Presumptive Eligibility for Pregnant Women Web page of the Medi-Cal website.

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12. Private Duty Nursing for Children and Adolescents Under EPSDT Detailed

Private duty nursing (PDN) for children and adolescents under 21 years of age is available under the Medi-Cal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. To be covered under EPSDT, PDN must be medically necessary to correct or make more tolerable the child's or adolescent's physical or mental condition. The determination of medical necessity is made case by case, taking into account the needs of the individual child or adolescent.

The child's treating physician is responsible for determining or recommending that PDN services are medically necessary. If the state's expert disagrees with the treating physician as to whether a particular child's service is medically necessary, the state is responsible for the decision based on the medical documentation provided. The child or the child's family may appeal the state's decision under the Medi-Cal fair hearing procedures.

In the past, a “level of care analysis” and “cost limit” were used to decide requests for PDN services under EPSDT, but that is no longer the case. Coverage of EPSDT PDN services is determined based on medical necessity for each case.

Requesting EPSDT PDN if enrolled only in a managed care plan
For EPSDT to cover PDN services for a child or adolescent enrolled in a Medi-Cal managed care plan, the provider must request PDN by submitting a request to the managed care plan. Each managed care plan has its own procedures for requesting services. Providers should contact the child's managed care plan for that specific information.

Requesting EPSDT PDN through fee-for-service Medi-Cal
If a child or adolescent receives Medi-Cal services through fee-for-service Medi-Cal, the provider can request PDN services directly through the electronic Treatment Authorization Request (eTAR) system, and submit the necessary documentation by selecting “Submit Freeform Attachments.”

Requesting EPSDT PDN if related to a California Children's Services eligible condition
If the requested PDN services relate to a California Children's Services (CCS) eligible medical condition, the request must be directed to the EPSDT Unit. Eligibility is decided by CCS. If CCS denies the request on the grounds that the PDN services are not related to a CCS condition, the request can then be submitted to either the child's managed care plan or through fee-for-service to determine if the services are covered under EPSDT.

Each Treatment Authorization Request (TAR) for PDN services must include the following documents:

For general information about EPSDT services, providers can visit the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Web page of the Department of Health Care Services (DHCS) website. The PDF document EPSDT – A Guide for States contains further information regarding EPSDT services, including but not limited to PDN.

Questions about coverage of PDN services under EPSDT can be directed to the DHCS Systems of Care Division, EPSDT Unit by phone at 1-855-347-9227 or by email at EPSDT@dhcs.ca.gov.

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13. Carbidopa and Levodopa Enteral Suspension is a New Medi-Cal Benefit

Effective for dates of service on or after January 1, 2017, HCPCS code J7340 (carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml) is a new Medi-Cal benefit.

The combination of carbidopa and levodopa is an enteral suspension used for the treatment of motor fluctuations in patients with advanced Parkinson's disease 18 years of age and older. Code J7340 must be billed with ICD-10-CM diagnosis code G20 (Parkinson's disease). A Treatment Authorization Request (TAR) is required for reimbursement.

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); inject drug a-d (17, 18)
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14. National Correct Coding Initiative Quarterly Update for April 2017

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for dates of service on or after April 1, 2017.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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15. May 2017 Medi-Cal Provider Seminar

The next Medi-Cal seminar is scheduled for May 23 – 24, 2017, 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 Conduent, the Fiscal Intermediary 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 May 9, 2017, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After May 9, 2017, 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 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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