Medi-Cal Update

Therapies | December 2019 | Bulletin 531

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1. October 2019 HCPCS Quarterly Update: Policy Updates

The October 2019 updates to the Healthcare Common Procedure Coding System (HCPCS) National Level II codes are available in the Quarter 4 HCPCS Policy (Medi-Cal) PDF. Only those codes representing Medi-Cal benefits effective October 1, 2018, are included in the list of updates.

Please refer to the 2018 HCPCS Level II code book for complete descriptions of these codes.

Providers should refer to the HCPCS Annual Update page for ongoing updates.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 32, 33, 41, 42); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12)
Clinics and Hospitals
General Medicine
chemo drug a-d (14, 15, 21); chemo drug e-o (2, 3, 17–19, 21–24); chemo drug p-z (15, 25, 26); inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25); ophthal (15–17, 19–22); surg integ (4, 5, 9)
Obstetrics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25)
Rehabilitation Clinics inject an over (1, 2); inject cd list (2, 4–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 34, 35); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 5, 10, 11, 14, 15, 17, 18, 22–26); modif used (12); non ph (12, 13, 24, 25)
Pharmacy inject an over (1); inject cd list (2–6, 10, 11, 13–15); inject drug a-d (9, 10); inject drug e-h (26, 32, 33, 41, 42); inject drug i-m (12, 15–17, 23); inject drug n-r (4, 9, 13, 17, 22–24)
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2. 2020 CPT Annual Update

The 2020 updates to the Current Procedural Terminology (CPT) codes are available in the 2020 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for dates of service on or after January 1, 2020. Please refer to the 2020 CPT code book for complete descriptions of these codes.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
cardio (9, 10); chemo an over (1); epsdt chdp school (5); eval (31); inject an over (1); inject cd list (9); medne neu (3, 4, 8); medne non (1); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); once (7); ophthal (2, 4, 10); ophthal cd (7); path drug (4); path micro (7); path molec (2, 64, 65); presum bill (10, 11); radi nuc (3, 4); surg bil mod (7); surg cardio (9); surg eye (1); tar and non cd1 (4, 6); tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10); vaccine (4)
Obstetrics eval (31); inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); once (7); path drug (4); path micro (7); path molec (2, 64, 65); presum bill (10, 11); radi nuc (3, 4); surg bil mod (7); tar and non cd1 (4, 6); tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10); vaccine (4)
Rehabilitation Clinics inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); non ph (9–11, 24, 27); vaccine (4)
Chronic Dialysis Clinics inject an over (1); inject cd list (9); modif (3); modif app (12, 13); modif used (6, 10); vaccine (4)
Inpatient tar and non cd2 (1); tar and non cd3 (4); tar and non cd4 (7); tar and non cd6 (2–5); tar and non cd8 (2–4); tar and non cd9 (1, 2, 5–7, 9, 10)
Local Educational Agencies loc ed bil cd (8, 10, 11, 14, 22); loc ed serv nurs (5); loc ed serv physican (5); loc ed serv psych (7); modif app (12, 13)
Vision Care modif app (12, 13); modif used vc (2); pro serv (4, 11, 17, 19, 20); pro serv cd (7, 8); rates max optom (2)
Pharmacy inject an over (1); inject cd list (9); presum bill (10, 11)
AIDS Waiver Program modif (3); modif app (12, 13)
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3. Podiatry Services Restored as Medi-Cal Covered Benefits

Effective for dates of service on or after January 1, 2020, podiatry services previously eliminated as part of the optional benefits exclusion are reinstated as full Medi-Cal benefits.

In addition, Welfare and Institutions (W&I) code, Section 14133.07 was recently amended to remove two visit limit and to remove the same TAR requirements for services by podiatrists as for physicians and surgeons.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Chiropractic
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
opt ben exc (1–4, 6, 7, 13)
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4. Audiology and Speech Therapy Services Restored as Medi-Cal Benefits

Effective for dates of service on or after January 1, 2020, audiology and speech therapy services previously eliminated as part of the optional benefits exclusion are reinstated as full Medi-Cal benefits.

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

Provider Manual(s) Page(s) Updated
Chiropractic
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Pharmacy
Psychological Services
Vision Care
opt ben exc (1–4, 6–8, 13, 16–18)
Audiology and Hearing Aids
Adult Day Health Care Centers
Rehabilitation Clinics
Therapies
audio (1, 3, 6); opt ben exc (1–4, 6–8, 13, 16–18); speech (1)
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5. National Correct Coding Initiative Quarterly Update for January 2020

The Centers for Medicare & Medicaid Services (CMS) are scheduled to routinely release the quarterly National Correct Coding Initiative (NCCI) in Medicaid payment policy updates. These mandatory national edits will be incorporated into the Medi-Cal claims processing system and will be effective for dates of service on or after January 1, 2020.

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

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6. Policy for Medical Supply Billing Codes Updated to DME Supply Billing Codes

Effective for dates of service on or after February 1, 2020, the following medical supply billing codes are updated to Durable Medical Equipment (DME) supply billing codes: HCPCS codes A4222, A4230 – A4232, A4483, A7002 – A7004, A7006 – A7008, A7010, A7012, A7013, A7016, B4035 and S8186. Note that codes A4230 – A4232 and A7008 are not benefits.

These HCPCS codes that describe items used in the operation of DME will no longer be medical supply codes on the List of Medical Supplies Billing Codes, Units and Quantity Limits. These HCPCS codes must be billed as DME supply codes.

Updates to Medical Supply Codes
Effective for dates of service on or after February 1, 2020, medical supply HCPCS codes are updated as follows:

A4223

Infusion supplies not used with external infusion pump, per cassette or bag. Use to bill all necessary supplies that are not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to administrative sets and syringes, tubing, extension tubing, connecting devices and port caps) for the administration, without a pump, of non-insulin drugs.

Bill one (1) quantity unit per each administrative/infusion set/kit or per each separate item (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 30 units per 27-day period require authorization.

Documentation of product cost (an invoice, manufacturer’s catalog page or price list) is required as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Refer to DME supply HCPCS code A4222 for infusion supplies used with an external infusion pump.

B4034 Enteral feeding supplies; syringe fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by syringe and maintain the feeding site.
B4036

Enteral feeding supplies; gravity fed. Use to bill supplies not otherwise on the List of Medical Supplies Billing Codes, Units and Quantity Limits (including but not limited to feeding/flushing syringe, administration sets, tubing, extension tubing, connecting devices and port caps) that are necessary to administer enteral feeding by gravity and maintain the feeding site.

For claims using HCPCS code B4034 and B4036, bill one (1) quantity unit per each administrative/supply set/kit or per each separate item, (for example, one extension tubing is equal to one unit). Claims billed for quantities exceeding 31 units per 27-day period require authorization.

HCPCS code B4034 and B4036 require documentation of product cost (an invoice, manufacturer’s catalog page or price list) as an attachment to the claim for reimbursement. The name of the item must be clearly identifiable on the documentation for reimbursement.

Note:

HCPCS code B4035, enteral feeding supplies (pump fed), is updated to a DME supply code.

Effective for dates of service on or after February 1, 2020, HCPCS codes B9998, B9999 and S1015 will be end-dated. Providers must bill the items using the following codes:

Updates to DME Supply Codes
HCPCS codes A4230 – A4232 and A7008 are no longer benefits. The table below specifies policy for new DME supply codes A4483, A7002 – A7004, A7006, A7007, A7010, A7012, A7013, A7016, B4035 and S8186. In addition, policy for codes A4222, A4224, A4225 and E0574 is as follows.


HCPCS Code
Description Taxable/Non-Taxable Frequency Limit, Any Provider
A4222 * + Infusion supplies for external drug infusion pump, per cassette or bag Non-taxable --
A4224 * + ^ Supplies for maintenance of insulin infusion catheter, per week Non-taxable 1 per week
A4225 * + ^ Supplies for external insulin infusion pump, syringe type cartridge, sterile, each Non-taxable 15 per month
A4483 * + ^ Moisture exchanger, disposable, for use with invasive mechanical ventilation Non-taxable (no change) 31 per month
A7002 * + Tubing, used with suction pump, each Non-taxable 4 per month
A7003 * + Administration set, with small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7004 * + Small volume nonfiltered pneumatic nebulizer, disposable Taxable (no change) 2 per month
A7006 * + Administration set, with small volume filtered pneumatic nebulizer Taxable (no change) 1 per month
A7007 * + Large volume nebulizer, disposable, unfilled, used with aerosol compressor Taxable (no change) 1 in 2 months
A7010 * + Corrugated tubing, disposable, used with large volume nebulizer, 100 ft Taxable (no change) 1 in 2 months
A7012 * + Water collection device, used with large volume nebulizer Taxable (no change) 2 per month
A7013 * + Filter, disposable, used with aerosol compressor or ultrasonic generator Taxable (no change) 2 per month
A7016 * + Dome and mouthpiece, used with small volume ultrasonic nebulizer Taxable (no change) 2 per year
B4035 * + ^ Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape Taxable 31 per month
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer Taxable (no change) 1 in 5 years
S8186 * + Swivel adaptor Non-taxable (no change) 2 in 12 months

*  This code must be billed with modifier NU. Modifiers RB and RR are not allowed.
+  This code is for patient-owned equipment.
^  This code must be billed using the “from-through” (block-billing) method when billing for more than one day of service.

HCPCS code A7016 may be reimbursed only when used with code E0574. Authorization for rental of code E0574 may be granted in increments of up to three months, both for the initial authorization and for reauthorization. Authorization for purchase of code E0574 may be granted for one device every five years. Claims for code E0574 must include modifier NU, RR or RB.

HCPCS code S8186 is not covered by Medicare and should be billed to Medi-Cal directly.

HCPCS codes A4224 and A4225 are reimbursable under the Presumptive Eligibility for Pregnant Women (PE4PW) program.

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

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Medical Transportation
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (1)
Audiology and Hearing Aids medi non hcp (1); tax (6–8, 10, 12, 13)
Durable Medical Equipment dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); tax (6–8, 10, 12, 13)
General Medicine
Obstetrics
Clinics and Hospitals
medi non hcp (1); presum bill (12)
Orthotics and Prosthetics dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1); tax (6–8, 10, 12, 13)
Pharmacy dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); dura inf (4, 6); dura oxy (25, 29, 30, 50, 52); mc sup (2, 8); medi non hcp (1); presum bill (12); tax (6–8, 10, 12, 13)
Therapies dura cd (9, 13, 14, 39); dura cd fre (1, 2, 5); medi non hcp (1)
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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



Note:

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