Medi-Cal Update

Pharmacy | May 2017 | Bulletin 895

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2. Providers to Report PPCs Using DHCS Secure Online Portal

Effective June 1, 2017, the Department of Health Care Services (DHCS) will no longer accept paper forms for reporting provider-preventable conditions (PPCs). DHCS began accepting online reporting of PPCs for Medi-Cal on April 3, 2017. The development of secure online submission is in response to provider requests to make PPC reporting easier. This new online process replaces the paper Medi-Cal Provider-Preventable Conditions (PPC) Reporting Form (DHCS 7107). The secure online reporting portal is available on the Instructions for online reporting of PPCs Web page of the DHCS website.

Providers must report health care-acquired conditions (HCACs) when they occur in an acute hospital inpatient setting, and report other provider-preventable conditions (OPPCs) when they occur in any health care setting, according to state law in Welfare and Institutions Code (W&I Code), Section 14131.11, as well as the Code of Federal Regulations (CFR) Title 42, Sections 434, 447 and 438. Providers must report PPCs for any Medi-Cal recipient when any PPC occurs that did not exist prior to the provider initiating treatment, even if the provider will not seek Medi-Cal reimbursement to treat the PPC.

More information about PPC reporting requirements, PPC definitions and mandatory payment adjustments is available on the Medi-Cal Guidance on Reporting Provider-Preventable Conditions Web page of the DHCS website. Providers may email questions about the new PPC process to PPCHCAC@dhcs.ca.gov.

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3. 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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4. 2017 ICD-10-CM Diagnosis Code Annual Update

A previously published NewsFlash article titled “Additional Information: 2017 ICD-10-CM Diagnosis Code Update” notified providers that, with the 2017 annual ICD-10-CM update, a number of diagnosis codes have been expanded for greater detail. The Medi-Cal Provider Manuals and the Family PACT Policies, Procedures and Billing Instructions manual are now updated to reflect these expansions. Deactivated codes have been removed.

Providers should use the new, expanded codes when billing for dates of service on or after October 1, 2016.

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Medical Transportation
Orthotics and Prosthetics
Therapies
cms comp (14)
Chronic Dialysis Clinics inject drug i-m (10); path chem (2–4, 6, 8–10)
Clinics and Hospitals chemo drug p-z (17); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Durable Medical Equipment cms comp (14); incont (8)
Family PACT ben fam rel (8, 10, 13); ben grid (13–15); lab (12–14, 26, 28)
General Medicine chemo drug p-z (17); cms comp (14); ev woman (16, 17); incont (8); inject drug i-m (10); medne neu (6); minor (3); ophthal (9); ophthal cd (2, 4, 6–8); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); prescript (5); radi dia ult (1); radi nuc (1); spec (2); surg eye (7, 11, 12)
Inpatient Services minor (3)
Long Term Care incont (8)
Obstetrics cms comp (14); ev woman (16, 17); inject drug i-m (10); minor (3); path chem (2–4, 6, 8–10); path micro (7); preg early (3, 8, 9, 11–13, 15, 16); radi dia ult (1); radi nuc (1)
Pharmacy cms comp (14); incont (8); inject drug i-m (10)
Psychological Services cms comp (14); spec (2)
Rehabilitation Clinics inject drug i-m (10)
Vision Care minor (3); pro serv cd (2–4, 6, 7)
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5. Incontinence Medical Supplies Billing Codes Spreadsheet and Policy Updates

The incontinence medical supply billing codes, descriptions, quantity limits and maximum allowable product costs (MAPCs) are in the new List of Incontinence Medical Supply Billing Codes spreadsheet linked in the Incontinence Medical Supplies section of the provider manual.

Effective for dates of service on or after July 1, 2017, the incontinence billing codes shown below have been updated. The billing codes shown below with an MAPC no longer require documentation of product cost attached to the claim. All the billing codes below will no longer require authorization when billing up to the quantity limit. In addition, the $165 cost limitation (including sales tax and the 38 percent markup) per patient, per calendar month without authorization will apply.

Billing Code (HCPCS) Description MAPC per each Quantity Limits without Authorization
T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each $0.37 200 in a 27-day period
T4530 Pediatric sized disposable incontinence product, brief/diaper, large size, each $0.47 200 in a 27-day period
T4531 Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each $0.77 200 in a 27-day period
T4532 Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each $0.92 200 in a 27-day period
T4534 Youth sized disposable incontinence product, protective underwear/pull-on, each $0.95 200 in a 27-day period
T4543 Adult sized disposable incontinence product, protective brief/diaper, triple extra large (XXXL), each By Report 200 in a 27-day period
T4544 Adult sized disposable incontinence product, protective underwear/pull-on, triple extra large (XXXL) or above, each By Report 120 in a 27-day period

Effective for dates of service on or after July 1, 2017, the incontinence billing code A4520 (incontinence garment, any type [e.g. brief, diaper], each) will no longer be reimbursable. All Medi-Cal covered incontinence medical supplies meet one of the descriptions of the billing codes on the List of Incontinence Medical Supply Billing Codes spreadsheet.

All incontinence medical supply billing codes are reimbursable only for recipients age 5 and older with a chronic pathologic condition causing the recipient's incontinence. The primary ICD-10-CM diagnosis code and the secondary ICD-10-CM diagnosis code must be entered on claims to reflect the condition causing the incontinence and the type of incontinence.

Authorization is required for incontinence claims exceeding the quantity limit or the $165 cost limit. The quantity billed with or without authorization must not exceed a one-month supply (total quantity approved divided by the number of months approved) in a 27-day period.

The maximum amount reimbursed to providers for incontinence medical supply billing codes is the lesser of:

The incontinence medical supply product dispensed must match the description on the List of Incontinence Medical Supply Billing Codes spreadsheet for the billing code on the claim for reimbursement.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (1, 2, 4, 7, 8, 10)
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6. Updates to the List of Contracted Wound Care Advanced Dressings

The List of Contracted Wound Care Advanced Dressings has been updated with an extended end date for certain products by the manufacturer Mölnlycke. The maximum acquisition cost (MAC) for these products is no longer guaranteed and will no longer be reimbursable effective for dates of service on or after October 1, 2017.

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7. Additions to the List of Contracted Ostomy Supplies

Effective for dates of service on or after May 1, 2017, the List of Contracted Ostomy Supplies has been updated. Products from the manufacturer Genairex have been updated with new item numbers, Universal Product Numbers (UPNs) and UPN qualifiers.

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8. Certification Statement Required for Medical Supply Invoice Attachments

Effective for dates of service on or after June 1, 2017, the Department of Health Care Services (DHCS) is adopting a policy requiring a self-certification statement on invoice attachments for medical supply claims. Providers are required to include the following certification statement exactly as written on all invoices and on each invoice page:

“I certify that I have properly disclosed and appropriately reflected a discount or other reduction in price obtained from a manufacturer or wholesaler in the costs claimed or charges on this invoice identified by item number _______________ as stated in 42 U.S.C. 1320a-7b (b) (3) (A) of the Social Security Act and this charge does not exceed the upper billing limit as established in California Code of Regulations Title 22, Section 51008.1 (a) (2) (D).”

The item claimed must be clearly identified on the invoice if the item number is not identified on the statement.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (10); mc sup ex (4, 5)
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9. Updated Drugs and Nutritional Products List Requiring SAR for CCS and GHPP

Effective retroactively for dates of service on or after July 1, 2015, Beneprotein powder 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).

Effective retroactively for dates of service on or after June 1, 2016, Sofosbuvir/Velpatasvir is added to the pharmacy list of drugs and nutritional products requiring a separate SAR for CCS and 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 (8); genetic (9)
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10. Updated PE4PW Patient Fact Sheet Available in 12 Languages

The Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet is updated and available in 12 languages:

Providers can access the updated fact sheets on the Presumptive Eligibility for Pregnant Women and Forms pages of the Medi-Cal website.

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

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11. June 2017 Medi-Cal Provider Training Webinars

Beginning June 1, 2017, and continuing throughout the month of June, Medi-Cal providers may participate in provider training webinars:

Providers will be able to print class materials and ask questions during the training sessions. Recorded webinars will be archived and available for on-demand viewing from the MLP.

To view the webinars, providers must have Internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach and Education page of the Medi-Cal website.

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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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