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September Updates: CHDP Phase 3 HIPAA Code Conversion: for School-Based Services

September 14, 2018

The Department of Health Care Services (DHCS) is initiating Phase 3 of the Child Health and Disability Prevention (CHDP) claim form transition and code conversion. To comply with HIPAA national standards for health care electronic transactions and code sets, school-based services will transition to national standards on November 1, 2018.

CHDP school-based providers will bill services directly to Medi-Cal in accordance with HIPAA national standards. Services will be billed with CPT-4 national codes on the UB-04 claim form or electronic equivalent. Services billed on the incorrect claim form for the date of service will be denied.

As a reminder, CHDP well-child health assessments and lab services conducted by school-based providers will continue to be performed in accordance with the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule.

Staying Informed: CHDP School-Based Providers
The following information is being released in September 2018 to keep CHDP school-based providers informed. This information is in addition to important instructions published on the Medi-Cal website in the July 2018 article,CHDP Phase 3 HIPAA Code Conversion: School-Based Services Crosswalk.

Condition Code Required on UB-04 Claim
CHDP school-based providers also bill services for children and youth who qualify for Local Educational Agency (LEA) services. To distinguish between LEA claims and CHDP services within the Medi-Cal claims processing system, school-based providers must enter condition code “A1” (EPSDT/CHDP) in the Condition Code field (Boxes 18 – 24) on the UB-04 claim to be reimbursed for CHDP services. Claims submitted for CHDP services that do not contain the condition code will be denied.

Instructions for entering the condition code on the claim are located in the UB-04 Completion: Outpatient Services section of the Medi-Cal provider manual.

Billing CHDP and LEA Services, Same Day, Same Recipient
CHDP and LEA services must be billed on separate claim forms to allow for reimbursement.

Providers may continue to submit claims on the Confidential Screening/Billing Report (PM 160) up to six months after the transition date, as long as the date of service is before November 1, 2018. For dates of service after November 1, 2018, providers must submit claims for school-based CHDP services to qualified children and youth on the UB-04 claim.

After implementation, providers will have six months from the Remittance Advice Details (RAD) date to submit follow-up documentation, including:

  • Notice of Claim Denial From Critical Edit Appeal
  • Fee Adjustment Appeal
  • Denied Claim Appeals
  • Fee Cut Appeal
  • Balance Due Request
  • Tracer

Correction: Code Conversion Table
The full code conversion is available in the CHDP Code Conversion Table. Subsequent to its first release on July 25, 2018, this code conversion table has changed as follows: CHDP local code 23 (blood draw) is now crosswalked to CPT-4 code 99000 (handling and/or conveyance of specimen for transfer from the [physician’s] office to a laboratory), rather than CPT-4 codes 36406 and 36410. In addition, CPT-4 code 92552 (pure-tone audiometry [threshold; air only]) is removed as a benefit.

Additional Information
For additional important information concerning this code conversion, refer to the already published article, CHDP Phase 3: School-Based Services Transition Coming Soon.

Providers are encouraged to subscribe to the Medi-Cal Subscription Service (MCSS) to receive notifications related to the upcoming changes. These notifications will inform and prepare providers to minimize unnecessary service disruptions. Providers may sign up for MCSS by completing the MCSS Subscriber Form.

Email Address for Questions/Concerns
Providers may submit questions or concerns regarding the CHDP Phase 3 school-based services code conversion and claim form transition to CHDPTransition@conduent.com. Including the following information will expedite a response to your inquiry: NPI number.

Manual updates will be released in a future CHDP Update bulletin.