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EPSDT Home Health Code Conversion and Billing Instructions

September 6, 2018

Effective for dates of service on or after January 1, 2019, HCPCS Level III local codes for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Home Health services will be discontinued. National HIPAA-compliant CPT Category I or HCPCS Level II codes will replace the local codes, which will be required on EPSDT Home Health claims. Providers submitting UB-04 claim forms or ANSI 837I transactions must bill revenue codes in addition to the national procedure codes.

For claims with dates of service on or after January 1, 2019, providers will use a combination of:

  • CPT Category I or HCPCS Level II codes; with a modifier, or
  • Revenue codes and CPT Category I or HCPCS Level II codes with a modifier.

HCPCS Level III local codes will only be valid for dates of service on or before December 31, 2018.Effective for dates of service on or after January 1, 2019, new Treatment Authorization Requests/Electronic Treatment Authorization Requests (TARs/eTARs) and new Service Authorization Requests/Electronic Service Authorization Requests (SARs/eSARs) for EPSDT Home Health services must include CPT Category I or HCPCS Level II national codes. The Crosswalk for this conversion is available on the HIPAA: Code Conversions webpage of the Medi-Cal website under the EPSDT services: Home Health heading:

Claims for existing TARs/eTARs authorized with through dates beyond January 1, 2019, may be submitted with HCPCS Level III local codes until the end-date of that TAR/eTAR.

Claims for existing SARs/eSARs authorized with through dates beyond January 1, 2019 may be submitted with HCPCS Level III local codes until the end-date of that SAR/eSAR.

If the submitted TAR/SAR is for updating the codes for the same authorization period, it will not be reviewed for medical necessity.

Updated manual pages will be released in a future Medi-Cal Update.