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HIPAA: EPSDT Home Health Code Conversion

Health Insurance Portability and Accountability Act (HIPAA) mandated changes to billing requirements for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) home health services will become effective on January 1, 2019.

HIPAA was passed by Congress in 1996. In addition to eliminating the use of HCPCS Level III local codes, HIPAA does the following:

  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs.
  • Reduces healthcare fraud and abuse.
  • Mandates industry-wide standards for health care information on electronic billing and other processes.
  • Requires the protection and confidential handling of protected health information.

California has historically used thousands of HCPCS Level III or local codes (also known as interim codes) for billing and reimbursement of services and supplies. National codes, such as CPT Category I or HCPCS Level II codes are typically more specific in nature compared to local codes. Using HIPAA-compliant CPT Category I or HCPCS Level II codes will:

  • Simplify processes and decrease the costs associated with payment for health care services.
  • Improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (for example, medical practices, hospitals and health care plans).
  • Provide standardization and consistency in medical service coding.
  • Characterize a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.

The use of a HIPAA-compliant CPT Category I or HCPCS Level II code is required to bill for the service visit with the recipient on or after January 1, 2019.

The claim may consist of the following:

  • CPT Category I or HCPCS Level II code with modifier(s);
  • Revenue code and CPT Category I or HCPCS Level II code with modifier(s).

For dates of service on or after January 1, 2019, claims submitted with HCPCS Level III local codes will be denied.

The following Frequently Asked Questions (FAQs) will provide an overview of some of the changes occurring during this conversion.

  1. What does the conversion from HCPCS Level III local codes to CPT Category I and HCPCS Level II codes mean for billing EPSDT home health services?

    Effective January 1, 2019, EPSDT home health services which are currently billed using HCPCS Level III local codes will require specified CPT Category I and/or HCPCS Level II national codes.

  2. What codes are changing in this code conversion?

    The following HCPCS Level III local Z-codes will be converting to CPT Category I or HCPCS Level II in this code conversion: Z5802, Z5804, Z5805, Z5806, Z5807, Z5832, Z5833, Z5834, Z5835, Z5836, Z5838, and Z5840.

    More information regarding local codes and national codes will be located on the crosswalk at the HIPAA: Code Conversions page under the EPSDT Home Health heading.

  3. What claim forms will I use to bill the national codes?

    The national codes in this code conversion may be billed on a CMS-1500 claim form or an outpatient UB-04 claim form with the following exceptions: services billed with G0156, G0162, G0299, G0300 T1002 and T1003 are billed on an outpatient UB-04 claim form only.

  4. What is EPSDT?

    EPSDT is a Medi-Cal benefit for recipients younger than 21 years of age who have full-scope Medi-Cal eligibility. This benefit allows for periodic screenings to determine health care needs. Treatment services are provided based upon the identified health care need and diagnosis. EPSDT services include all services covered by Medi-Cal. In addition to regular Medi-Cal benefits, recipients younger than 21 years of age may receive additional medically necessary services.

  5. What are home health services?

    Home health services are reimbursable outpatient benefits that are prescribed by a physician and provided at the recipient’s home in accordance with a written treatment plan reviewed by a physician every 60 days.

    More information regarding home health services can be found in the Home Health Agencies (HHA) (home hlth) section of the appropriate part 2 provider manual.

  6. Are face-to-face encounters required for services provided by a home health agency?

    Yes. Effective for dates of service on or after July 1, 2017, Code of Federal Regulations (CFR) Title 42, Section 440.70 requires Medicaid programs to require a face-to-face encounter prior to delivery of services by a home health agency.

    The face-to-face encounter must be administered by a physician, nurse practitioner, clinical nurse specialist, physician assistant or certified nurse midwife and must be related to the primary reason the recipient requires home health services. The encounter must occur within 90 days before or within 30 days after the start of services. If the provider performing the face-to-face encounter is not the physician, the provider must communicate the clinical findings of that face-to-face encounter to the ordering physician.

  7. Are there codes billed in increments?

    Yes, there are codes billed by increments of service; either 15 minutes, 30 minutes, hourly or per day. The exact codes can be found on the crosswalk, which will be located on the HIPAA: Code Conversions page under the EPSDT Home Health heading.

  8. What is a modifier code?

    Modifier codes are two-character codes used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Modifiers help further describe a procedure code without changing its definition. Omitting or billing with incorrect modifiers can result in inaccuracies with provider reimbursement and health service records.

  9. What specific modifiers will I need to use to bill for EPSDT home health claims?

    Modifier code EP (service provided as part of Medicaid EPSDT) will allow for the distinction between home health services rendered to children and home health services rendered to adults. It will be applicable for dates of service on or after January 1, 2019.

    Modifier code TD – (Registered Nurse [RN]) will be applicable for national code T1016 only.

    For more information regarding modifiers please refer to the Modifiers: Approved List (modif app) in the appropriate part 2 provider manual.

  10. What is a revenue code?

    A revenue code identifies specific accommodations, ancillary service, or unique billing calculations or arrangements. Revenue codes are four digits and accompany CPT Category I and HCPCS Level II national procedure codes billed on a claim.

  11. Will a revenue code be required for all EPSDT home health claims?

    Revenue codes are not required on CMS-1500 claim forms or ANSI 837P transactions.

    For dates of service on or after January 1, 2019, a four-digit revenue code must be included on outpatient claims billed on paper UB-04 claim forms or ANSI 837I for electronic billing.

    Outpatient claims with dates of service on or after January 1, 2019, which are submitted on paper UB-04 claim forms or ANSI 837I transactions with missing, incomplete, or invalid revenue codes will be denied.

    See the NewsFlash article Valid Revenue Codes for Outpatient Services for additional information.

  12. Will I need to update my billing software?

    Updates may be needed. It is recommended that providers inquire with their vendors and billing/system contractors to determine if any software changes will be needed and make the necessary changes when applicable.

  13. How do I test/validate that my system changes are compatible with the code conversion?

    Submitters may test status to ensure accurate file format, completeness and validity for HIPAA compliant claims transactions by logging into the Medi-Cal test site using their submitter ID and password. Instructions for Computer Media Claims (CMC) testing can be found in the Testing and Activation Procedures section of the CMC Billing and Technical Manual.

  14. How will the conversion impact claims that are billed with dates of service prior to and after January 1, 2019?

    Continue to bill with HCPCS Level III local codes for dates of service prior to January 1, 2019. Begin billing HIPAA-compliant CPT Category I or HCPCS Level II codes for dates of service on or after January 1, 2019.

  15. Are SARs and eSARs required for a CCS/GHPP beneficiaries when submitting EPSDT claims?

    A Service Authorization Request (SAR)/electronic SAR (eSAR) is required for California Children’s Services (CCS)/Genetically Handicapped Persons Program (GHPP) eligible beneficiaries under 21 years of age. If a recipient under 21 years of age is not eligible for CCS/GHPP a Treatment Authorization Request (TAR) will be used for EPSDT services.

  16. How will this conversion impact my SARs/eSARs?

    HCPCS Level III local codes will only be valid for dates of service ending on or before December 31, 2018. Effective for dates of service on or after January 1, 2019, new SARs/eSARs for EPSDT home health services must include CPT Category I or HCPCS Level II national codes.

    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.

    For more information on SAR and eSAR submissions please refer to the California Children’s Services (CCS) Program Service Authorization Request (SAR) (cal child sar) section of the appropriate part 2 provider manual.

  17. How will this conversion impact my TARs and electronic TARs (eTARs)?

    HCPCS Level III local codes will only be valid for dates of service ending on or before December 31, 2018. Effective for dates of service on or after January 1, 2019, new TARs/eTARs for EPSDT home health services must include CPT Category I or HCPCS Level II national codes.

    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.

    For more information on TAR and eTAR submissions please refer to the TAR Completion (tar comp) section of the appropriate part 2 provider manual.

  18. What is a Service Code Grouping (SCG)?

    An SCG is a group of procedure codes available to a CCS-approved provider for the provision of a group of related health care services that are authorized through the SAR/eSAR process. An SCG SAR/eSAR enables the provider to render care to a CCS or GHPP client without obtaining repeated procedure-specific SARs/eSARs.

    For more information regarding Service Code Groupings, please refer to the California Children’s Services (CCS) Program Service Code Groupings (cal child ser) section of the appropriate part 2 provider manual.

  19. Who can I contact if I have additional questions or concerns?

    Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border Providers and Out-of-State Billers billing for In-State Providers call (916) 636-1200. Providers calling from outside of California call the Out of-State Provider Unit at (916) 636-1960 from 8 a.m. to 5 p.m. Monday through Friday, except holidays.

    For electronic claim submission questions the CMC Help Desk can be accessed by calling the TSC at 1-800-541-5555 and selecting the option Point of Service (POS), internet, Lab Service Reservation System (LSRS) and CMC inquiries.

    All other questions for the EPSDT Services: Home Health Code Conversion may be submitted via email to CAMMISCodeConversion@conduent.com.