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CHDP Phase 2 HIPAA Code Conversion: Corrected Crosswalk and Manual Updates

June 16, 2017

Child Health and Disability Preventions (CHDP) providers bill services directly to Medi-Cal in accordance with HIPAA national standards. Billing with CPT-4 or HCPCS national codes on the CMS-1500, UB-04 claim forms or electronic equivalents is occurring in two phases:

Phase 1:

Transitions clinical laboratory-only services effective for dates of service on or after February 1, 2017

Phase 2:

Transitions remaining CHDP services effective for dates of service on or after July 1, 2017

Services billed on the incorrect claim form for the date of service will be denied.

In addition to meeting HIPAA standards, this transition adapts CHDP billing to the American Academy of Pediatrics (AAP) February 2017 Bright Futures periodicity schedule and enhanced Bright Futures services.

Code Conversion Table Correction
The CHDP Code Conversion Table released in both April and May, 2017 Medi-Cal Update bulletins has been corrected. CPT-4 code 90632 (hepatitis A vaccine, adult dosage) with modifier SL (state-supplied vaccine) has been removed from page 10. Medi-Cal does not reimburse for this code combination. To view the full code conversion and additional instructions, providers may refer to the CHDP Code Conversion Table.

CHDP Program
The CHDP program reimburses for outpatient preventive health services for eligible children and youth. In California, the CHDP program provides the early and periodic screening component of the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit for Medi-Cal recipients.

Confidential Screening/Billing Report (PM 160)
Providers will continue to bill services on the Confidential Screening/Billing Report (PM 160) claim form only as follows:

  • Clinical laboratory-only services: Dates of service prior to February 1, 2017
  • Other CHDP services: Dates of service prior to July 1, 2017

FQHC, RHC, IHS/MOA Billing
Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services/Memorandum of Agreement 638 (IHS/MOA) clinics will continue to bill using the UB-04 claim with the Confidential Screening/Billing Report Information Only (PM 160 Information Only) for reporting purposes, if required.

Delayed Transition: School-Based Services
Providers who render CHDP services in a school-based setting are not transitioning under Phase 2 as previously communicated. These providers will continue billing these services using the PM 160 claim form, until further notice.

CHDP Manual Updates
The CHDP Transition to National Standards section in the CHDP Provider Manual has been updated with lists of CPT-4 and HCPCS codes providers use when billing qualified CHDP/EPSDT services to Medi-Cal.

The other sections in the CHDP Provider Manual are retained to help providers still billing on the PM 160. Boxed text has been added on page 1 of each section to remind providers that when billing CPT-4 and HCPCS codes on the national claim forms, they should refer to the CHDP Transition to National Standards section. Sections with boxed text will be retained for reference until the Department of Health Care Services (DHCS) directs their removal.

Medi-Cal Manual Updates
Policy reflecting the changes occurring under the CHDP transition has also been updated in several Medi-Cal Part 1 and Part 2 provider manual sections. For example, the range of codes reimbursable for preventive medicine services for children in the Evaluation and Management (E&M) section has been expanded to include CPT-4 codes 99385 and 99395.

Billing
It is recommended that providers bill electronically. Providers who are not able to bill electronically and do not have a supply of national claim forms should order them. Providers should work with a credible vendor and purchase forms with “drop-out” ink that meet Centers for Medicare & Medicaid (CMS) standards.

Note: To bill, CHDP providers must have an active Medi-Cal NPI.

Information submitted on CMS-1500 and UB-04 claim forms does not need to be forwarded to county CHDP offices, as was required with the CHDP PM 160.

Medi-Cal provider manual sections with CMS-1500 or UB-04 claim submission, follow-up and completion information are as follows:

Task or Service Provider Manual Sections
Claim Submission
  • CMS-1500 Completion: This section contains field by field instructions for entering information on the CMS-1500 claim form.
  • UB-04 Completion: Outpatient Services. This section contains field by field instructions for entering information on the UB-04 claim form.
Claim Follow-up
  • CIF Completion: This section contains information about claim adjustments, reconsiderations and tracers.
Health Assessments
  • Evaluation and Management: Refer to the “Preventive Medicine Services for Children” entry.
  • Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT-4 and HCPCS Level II codes.
  • For information about HCPCS code S3620 (newborn metabolic screening):
  • Genetic Counseling and Screening

    Genetic Screening Billing Examples: CMS-1500
Laboratory
  • Pathology: An Overview of Enrollment and Proficiency Testing Requirements. This section includes information about Medi-Cal enrollment and proficiency requirements for laboratories and pathologists.
  • Pathology: Billing and Modifiers. This section includes information about the billing and reimbursement of pathology services.
  • Pathology Billing Example: CMS-1500. This section illustrates how to bill the same lab procedure more than once on the same day.
  • Pathology Billing Examples: UB-04. This section illustrates how to bill the same lab procedure more than once on the same day and shows how an outpatient hospital bills for laboratory tests performed by an unaffiliated laboratory.
  • Various other pathology related sections: The Medi-Cal provider manual contains pathology sections tailored to the type of lab services. For example, a provider billing for CPT-4 code 82947 (blood glucose) will find information about that code in the Pathology: Chemistry section.
  • Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT-4 and HCPCS Level II codes.
Vaccines
  • Immunizations: Refer to the “Preventive Medicine Services for Children” entry.
  • Vaccines For Children (VFC) Program
  • Non-Physician Medical Practitioners (NMP)
  • Correct Coding Initiative: National. This section provides information about how the National Correct Coding Initiative (NCCI) may impact claims. NCCI edits are designed to control incorrect coding combinations or unlikely excessive services reported on claims with CPT-4 and HCPCS Level II codes.

For providers who are not actively billing on CMS-1500 or UB-04 claim forms, a claim completion, computer-based training (CBT) course is available through the Medi-Cal Learning Portal (MLP).

Reimbursement
CHDP/EPSDT services billed with national codes on the CMS-1500, UB-04 or electronic equivalent are reimbursable at Medi-Cal rates. The Medi-Cal rates table may be accessed from the Medi-Cal website: Under the References tab, providers click on “Medi-Cal Rates.” Payment will be made on providers’ Medi-Cal warrant for claims processed with dates of service on or after February 1, 2017 (laboratory-only services) or on or after July 1, 2017 (other CHDP services).

Providers may continue to receive 1099s from both the CHDP system and Medi-Cal CA-MMIS system up to one year from implementation, based on the dates of service billed on claims.

Services Rendered before the Transition
CHDP services rendered before February 1, 2017 (laboratory-only services) or before July 1, 2017 (other CHDP services) will continue to be submitted on the Confidential Screening/Billing Report (PM 160) claim form until a year from the date of service. Claim responses, notifications, payment, appeals and similar processes will continue as indicated in the Child Health and Disability Prevention (CHDP): Claims Processing section of the CHDP Provider Manual.

Email Address for Questions/Concerns
Providers may submit questions or concerns regarding the CHDP code conversion and claim form transition to CHDPTransition@conduent.com.

For manual replacement pages reflecting these changes please refer to this month’s CHDP Updateand Medi-Cal Update bulletins