Medi-Cal Update

Pharmacy | February 2020 | Bulletin 961

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1. Correction: 2020 HCPCS Policy Updates PDF Reposted with Updated Policy

A previously published Medi-Cal Update article titled “2020 HCPCS Annual Update” included an incorrect version of the 2020 HCPCS Policy Updates PDF. The correct 2020 updates to the HCPCS codes, along with updated policy for HCPCS code K1005, are available in the 2020 HCPCS Policy Updates PDF.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Orthotics and Prosthetics
Pharmacy
Therapies
dura cd fre (5)
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2. Medi-Cal Pharmacy Provider Self-Attestation Underway

On January 15, 2020, the online attestation portal opened for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the reimbursement for covered outpatient drugs. During the second week of January 2020, Medi-Cal pharmacy providers should have received a mailer that includes the URL for the online attestation portal, as well as a unique login ID and password.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this methodology is a two-tiered professional dispensing fee based on a pharmacy provider’s total (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process. The claim volume report will be submitted electronically and must be repeated annually.

Note:

DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for the total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing fewer than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete this attestation in order to receive it.

The attestation period for the 2019 calendar year is open from January 15, 2020, through February 29, 2020. The web portal will close at 11:59 p.m. on February 29, 2020, and attestations will not be accepted after that time. The attestation for the 2019 calendar year reporting period will determine the professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service within the state’s following fiscal year (dates of service from July 1, 2020, through June 30, 2021).

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs on the Medi-Cal website or the Pharmacy Reimbursement Project page on the DHCS website. For inquiries not covered in either, providers may call the Telephone Service Center at 1-800-541-5555 (outside of California, call [916] 636-1960), and select the following options:

  1. Option 1 for English or option 2 for Spanish

  2. Option 1 for Provider

  3. Option 4 for Technical Help Desk

  4. Option 2 for Pharmacy

  5. Option 1 for Provider

  6. Option 1 for NPI – enter NPI followed by the pound (#) sign

  7. Option 2 for Pharmacy

After following the steps above, the caller will be directed to an agent.

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3. 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. Until further notice, the following items continue to be reimbursable as medical supply codes and are not yet reimbursable 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.

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4. Durolane Added as a Medi-Cal Benefit

Effective for dates of service on or after March 1, 2020, HCPCs code J7318 (Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg) has been added as a benefit.

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 (8); inject drug e-h (43–45)
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5. Clarification of Billing Codes for Initial Antepartum Office Visits

Effective for dates of service on or after March 1, 2020, only primary obstetrical providers are to bill with HCPCS codes Z1032 (initial antepartum office visit) and Z1034 (antepartum follow-up office visit). All other providers must bill with Evaluation and Management (E&M) consultation codes 99241 – 99245.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals altern (4); preg com exu (2); preg com lis (1); preg early (3, 4); preg ex ub (2, 11); preg glo (1); preg per cd (1); preg share (1); presum bill (15)
General Medicine
Obstetrics
altern (4); preg com exc (2, 5); preg com lis (1); preg early (3, 4); preg glo (1); preg per cd (1); preg share (1); presum bill (15)
Pharmacy presum bill (15)
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6. March 5, 2020 Medi-Cal Provider Seminar

The March Medi-Cal provider seminar is scheduled for March 5, 2020 at Concord Crowne Plaza Hotel in Concord, 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 Medicaid Management Information System (CA-MMIS) Fiscal Intermediary (FI) 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 February 17, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date of training. After February 17, 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 claims 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 request a custom billing workshop, presented by a regional field representative. To schedule the regional representative for your area, providers must 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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7. March 2020 Medi-Cal Seminar

The March Medi-Cal provider seminar is scheduled for March 24, 2020, at the Flamingo Conference Resort and Spa in Santa Rosa, 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 Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both new and experienced providers and billing staff, cover the following topics:

Providers must register by March 9, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date of training. After March 9, 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 who 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 request a custom billing workshop presented by a field representative. To schedule the field representative for their area, providers must contact Provider Call Center (PCC) at 1-800-541-5555 and request to be contacted by a field representative.

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

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8. April 2020 Medi-Cal Provider Seminar

The April Medi-Cal provider seminar is scheduled for April 14–15, 2020, at the Riverside Convention Center in Riverside, 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 March 27, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After March 27th, 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 page and refer to it often for current seminar information.

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9. Authorization for Incontinence Creams and Washes

The November 2019 Medi-Cal Update notified providers that, effective for dates of service on or after January 1, 2020, incontinence creams and washes require authorization. Effective for dates of service on or after January 1, 2020, products in the List of Contracted Incontinence Creams and Washes billed using HCPCS codes A4335 (incontinence supply; miscellaneous) and A6250 (skin sealants, protectants, moisturizers, ointments, any type, any size) are reimbursable for recipients 5 years of age or older with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). An approved non-product-specific SAR will continue to be reimbursable up to the allowable quantity limits provided in the List of Incontinence Medical Supply Billing Codes.

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10. Wound Care Advanced Dressings No Longer Contracted

Effective for dates of service on or after April 1, 2020, the wound care advanced dressings HCPCS billing codes have the following updates:

Providers may refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet for the specific HCPCS billing code policy.

Reminders:

A signed and dated prescription written by a physician is required, ordering only those medical supplies necessary for the care of the recipient and as documented in the recipient’s medical record. The number of wounds being treated must also be documented. The prescription must be dated within 12 months of the date of service on the claim. The HCPCS billing code on the claim must be appropriate for the medical supply dispensed.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1)
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12. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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