Medi-Cal Update

Rehabilitation Clinics | April 2018 | Bulletin 523

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1. Cardiac Rehabilitation is a New Medi-Cal Benefit

Effective for dates of service on or after April 1, 2018, the following CPT-4 and HCPCS codes are Medi-Cal benefits for cardiac rehabilitation:

CPT-4
Code
Description
93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitor (per session)
93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
HCPCS
Code
Description
G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session

Treatment Authorization Request (TAR) Requirements
A TAR is required for HCPCS codes G0422 and G0423. A TAR approval requires documentation that a patient meets diagnostic criteria for cardiovascular rehabilitation, and that the program be a CMS-approved intensive cardiovascular rehabilitation program. CPT-4 codes 93797 and 93798 may not be reimbursed in the same calendar month as HCPCS codes G0422 and G0423, for any provider. Similarly, HCPCS codes G0422 and G0423 may not be reimbursed in the same calendar month as CPT-4 codes 93797 and 93798, for any provider.

Modifiers SA, U7, 24, 25 and 99 are all allowable for CPT-4 codes 93797 and 93798, as well as HCPCS codes G0422 and G0423.

Qualified Practitioners
Licensed practitioners who are eligible for reimbursement of CPT-4 codes 93797 and 93798 include physicians, physician assistants, nurse practitioners and physical therapists.

Licensed practitioners who are eligible for reimbursement of HCPCS codes G0422 and G0423 include physicians, physician assistants, nurse practitioners, psychologists, licensed clinical social workers, marriage and family therapists and physical therapists.

ICD-10-CM Diagnosis Codes
When billing for CPT-4 codes 93797 and 93798 or HCPCS codes G0422 and G0423, the claim must include one of the following:

I20.1 – I22.9 I25.761 – I25.769 I70.411 – I70.413
I25.111 – I25.119 I25.791 – I25.799 I70.511 – I70.513
I25.701 – I25.709 I50.22 I70.611 – I70.613
I25.711 – I25.719 I50.32 I70.711 – I70.713
I25.721 – I25.729 I50.42 Z95.1
I25.731 – I25.739 I70.211 – I70.213 Z95.5
I25.751 – I25.759 I70.311 – I70.313 Z98.61

Frequency Restrictions
Providers may bill CPT-4 codes 93797 and 93798 for a maximum of two one-hour sessions of cardiovascular rehabilitation per day and up to 24 one-hour sessions over a 24-week period. The combined total number of sessions billed with CPT-4 codes 93797 and 93798 must not exceed 24 in a 24-week period. A TAR may be used to override the frequency limit.

Providers may bill HCPCS codes G0422 and G0423 for a maximum of six one-hour sessions of intensive cardiovascular rehabilitation per day and up to 72 one-hour sessions over an 18-week period. The combined total number of sessions billed with HCPCS codes G0422 and G0423 must not exceed 72 in an 18-week period. A TAR may not be used to override the frequency limit.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinic modif used (9)
Clinics and Hospitals
General Medicine
Obstetrics
modif used (9); non ph (9); tar and non cd9 (4)
Inpatient Services tar and non cd9 (4)
Rehabilitation Clinics modif used (9); non ph (9); rehab (4–9)
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2. Benefit Updates for Antihemophilic Factors Afstyla and Kovaltry

Effective for dates of service on or after April 1, 2018, HCPCS codes J7210 (injection, factor VIII, antihemophilic factor, recombinant, Afstyla 1 IU), and code J7211 (injection, factor VIII, antihemophilic factor, recombinant, Kovaltry, 1 IU) are Medi-Cal benefits. Codes J7210 and J7211 may be billed with modifiers U7 and 99 for physician assistant services and SA and SB for non-physician medical practitioner services, as well as modifier UD for all providers.

Additionally, HCPCS code C9140 (injection, factor VIII, antihemophilic factor, recombinant, Afstyla 1 IU) is no longer a Medi-Cal benefit.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
blood (2, 3)
Clinics and Hospitals
General Medicine
blood (2, 3); non ph (11, 12)
Obstetrics
Rehabilitation Clinics
non ph (11, 12)
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3. Manual Updates: Online PDF RAD and Medi-Cal Financial Summary

General information about the new PDF RAD has been added to the Medi-Cal provider manual.

Providers can securely view and download a PDF version of their paper Remittance Advice Details (RAD) and Medi-Cal Financial Summary from the Transactions tab of the Medi-Cal website home page.

Note:

To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

PDF RAD User Guide Reminder
The PDF RAD Web Portal User Guide is available on the Medi-Cal website. The user guide contains step-by-step instructions to help providers view and download the PDF version of their RAD. Providers may download the guide from the User Guides page of the Medi-Cal website.

 

Benefits of PDF RAD
There are many benefits to accessing RAD and Medi-Cal Financial Summary information online:

No provider payments are made via PDF RADs. They are informational only.

835 Transactions
Providers also are encouraged to sign up for the ASC X12N 835 transaction using the Electronic Health Care Claim Payment/Advice Receiver Agreement form (DHCS 6246). The form is located on the Forms page of the Medi-Cal website. The Medi-Cal website contains 835 transactions generated for the last six weeks. For information about 835 transactions, providers may refer to “ASC X12N 835 Transaction” in the Part 1 Medi-Cal provider manual section, Remittance Advice Details (RAD): Electronic.

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

Provider Manual(s) Page(s) Updated
Part 1 remit (1); remit and (3); remit elect (4)
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Long Term Care
Medical Transportation
Multipurpose Senior Services Program
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
remit adv (1)
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4. TAR Requirements for Diclofenac Sodium Injection

Effective for dates of service on or after May 1, 2018, ICD-10-CM diagnosis codes J45.50 and J82 are no longer required when billing for HCPCS code J1130 (injection, diclofenac sodium, 0.5 mg). Instead, providers are required to submit an approved Treatment Authorization Request (TAR) when billing. The TAR must document the following:

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 drug a-d (36)
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5. ICD-10-CM Diagnosis Codes No Longer Required for Vitamin B-12 Injection

Effective for dates of service on or after May 1, 2018, HCPCS code J3420 (injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg) no longer requires an ICD-10-CM diagnosis code 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 drug s-z (20)
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6. Expansion of Providers that can Authorize NEMT Services

Effective for dates of service on or after January 1, 2018, the list of Medi-Cal providers that can authorize non-emergency medical transportation (NEMT) has expanded to include the following provider types:

NEMT necessary to obtain medical services is covered subject to the written authorization of a licensed practitioner consistent with their scope of practice. Additionally, if the non-physician medical practitioner is under the supervision of a physician, then the ability to authorize NEMT also must have been delegated by the supervising physician through a standard written agreement.

PAs, NPs and CNMs may sign authorization forms required by the department for covered benefits and services that are consistent with applicable state and federal law and are subject to the supervising physician and PA/NP/CNM being enrolled as Medi-Cal providers pursuant to Article 1.3 (commencing with Section 14043) of Chapter 7 Part 3 of Division 9 of the Welfare and Institutions Code (W&I Code).

PAs, NPs or CNMs may not sign authorization forms for the following covered benefits and services due to restrictions in Title 42 of Code of Federal Regulations Section 440.70 for home health services, Section 418.00 for hospice care or any other federal restriction for Medicaid. Restrictions include the following benefits and services:

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non ph (1)
Medical Transportation mc tran gnd (4); mc tran air (5)
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7. New Medi-Cal Benefits for Services Related to Alcohol Misuse

Effective for dates of service on or after May 1, 2018, HCPCS codes H0049 (alcohol and/or drug screening) and H0050 (alcohol and/or drug services, brief intervention, per 15 minutes) are replaced by HCPCS codes G0442 (annual alcohol misuse screening, 15 minutes) and G0443 (brief face-to-face behavioral counseling for alcohol misuse, 15 minutes).

HCPCS code G0442 is limited to one screening per year, any provider, unless otherwise medically necessary. Code G0443 may be billed on the same day as code G0442 and is limited to three sessions per recipient per year, any provider, unless otherwise medically necessary.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
non ph (9); prev (1, 2)
Obstetrics
Rehabilitation Clinics
non ph (9)
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8. Notice of Code Conversion for Audiology/EPSDT Audiology and Speech Therapy

The Audiology/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Audiology and Speech Therapy code conversion replaces non-HIPAA-compliant HCPCS Level III codes, commonly referred to as local codes, with HIPAA-compliant Current Procedural Terminology – 4th Edition (CPT-4) Level I or HCPCS Level II national codes. HIPAA mandated these changes to billing requirements for Audiology/EPSDT Audiology and Speech Therapy providers.

For claims with dates of service on or after the policy effective date of January 1, 2019, providers will use a combination of revenue codes, revenue codes and CPT-4 or HCPCS codes, or revenue codes and CPT-4 or HCPCS codes with a modifier.

Crosswalks and Frequently Asked Questions (FAQs) will be available soon and additional information for this project will publish as details are determined. Providers are encouraged to routinely check the Medi-Cal Update provider bulletins and complete the MCSS Subscriber Form to receive email notifications for newly published Medi-Cal Update bulletins, Newsflash articles and/or System Status Alerts.

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9. 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, 2018
NDC Labeler Code Contracting Company's Name
00316 CROWN LABORATORIES, INC.
10599 INTERSECT ENT, INC.
24201 CUSTOPHARM, INC. DBA LEUCADIA PHARMA
66794 PIRAMAL CRITICAL CARE
69680 VITRUVIAS THERAPEUTICS, INC.
69794 ULTRAGENYX PHARMACEUTICAL INC.
70482 ADAMAS PHARMA LLC
71143 OPTINOSE US, INC.
71287 KITE PHARMA, INCORPORATED
71394 SPARK THERAPEUTICS, INC.
71399 AKRON PHARMA INC.
   
Terminations, effective April 1, 2018
NDC Labeler Code Contracting Company's Name
42192 ACELLA PHARMACEUTICALS, LLC
67546 ROMARK LABORATORIES

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 (4, 6–8, 16–20)
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10. National Correct Coding Initiative Quarterly Update for April 2018

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 valid for dates of service on or after April 1, 2018.

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

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11. May 2018 Medi-Cal Provider Seminar

The May Medi-Cal provider seminar is scheduled for May 15 – 16, 2018, at the Double Tree Hilton in Fresno, 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 DHCS 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 May 1, 2018, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After May 1, 2018, 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. On the Lookup Regional Representative web 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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12. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

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  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

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For more information about MCSS, please visit the MCSS Help page.

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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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