Medi-Cal Update

Rehabilitation Clinics | April 2017 | Bulletin 511

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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. 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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5. 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, 2017
NDC Labeler Code Contracting Company's Name
13517 E5 PHARMA, LLC
51267 OREXIGEN THERAPEUTICS, INC.
63646 TOLMAR, INC.
69051 PROFOUNDA, INC.
69639 HELSINN THERAPEUTICS (U.S.), INC.
69660 CLOVIS ONCOLOGY, INC.
70000 CARDINAL HEALTH 110, LLC. DBA LEADER
70688 KASTLE THERAPEUTICS, INC
70710 ZYDUS PHARMACEUTICALS (USA) INC.
Terminations, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
66593 VIRO PHARMA, INC.

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 (6, 11, 14, 16, 18, 19)
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6. 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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7. 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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8. 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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9. 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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10. Policy Update: ECMO/ECLS Age Groups

Effective retroactively for dates of service on or after January 1, 2015, Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Life Support (ECLS) procedures will cover all ECMO/ECLS codes for all age groups (0 – 5 years of age and 6 – 99 years of age).

The following CPT-4 codes are Medi-Cal benefits for ECMO/ECLS procedures that will cover all age groups (0 – 5 years of age and 6 – 99 years of age):

CPT-4 Code Description
33946 Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947 initiation, veno-arterial
33948 daily management, each day, veno-venous
33949 daily management, each day, veno-arterial
33951 insertion of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33953 insertion of peripheral cannula(e), open, birth through 5 years of age
33955 insertion of peripheral cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33957 reposition of peripheral cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33959 reposition of peripheral cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33963 reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33965 removal of peripheral cannula(e), percutaneous, birth through 5 years of age
33969 removal of peripheral cannula(e), open, birth through 5 years of age
33985 removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33987 Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS
33988 Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
33989 Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

In order to perform ECMO/ECLS for infants, the institution must be a California Children’s Services (CCS) approved Neonatal Intensive Care Unit (NICU) as both a regional NICU and an ECMO center. The institution must also be capable of providing inhaled nitric oxide services for neonates for children.

In order to perform ECMO for recipients awaiting lung transplantation, the institution must be a Medi-Cal approved Center of Excellence for lung transplantation and have performed ECMOs on adults for a minimum of three years and performed an average of five ECMOs per year.

Daily overall management of the recipient may be separately reported using the relevant hospital inpatient services or critical care evaluation and management codes (99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 and 99480) and may be reimbursed to any provider, same recipient and same date of service.

Services must be submitted on the claim with all revenue/sick baby codes applicable to the entire stay. An infant claim must be submitted for services rendered to the baby only. Care for the mother is billed separately.

The following are revenue codes for ECMO services provided to newborns, infants and children, and adults:

Revenue Code Description
174 Nursery, Newborn; Level IV (newborn 0-28 days)
202 Intensive Care, Medical (adults)
203 Intensive Care, Pediatric (infants and children)

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
Chronic Dialysis Clinics
Rehabilitation Clinics
modif used (11)
Clinics and Hospitals
General Medicine
medne (4–7); modif used (11); tar and non cd3 (5, 6)
Inpatient Services medne (4–7); tar and non cd3 (5, 6)
Obstetrics modif used (11); tar and non cd3 (5, 6)
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11. 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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12. 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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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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