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Medi-Cal Update

Clinics and Hospitals | May 2021 | Bulletin 560

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1. New NDC for Moderna COVID-19 Vaccine

Moderna has introduced a new National Drug Code (NDC), 80777027315, for their coronavirus disease 2019 (COVID-19) vaccine. Medi-Cal will accept and adjudicate pharmacy claims for dates of service on or after April 1, 2021, that use this NDC when billing for the administration of either dose of the Moderna COVID-19 vaccine.

The Moderna COVID-19 Vaccine web page is updated to reflect this change. All other billing policy, regardless of NDC billed, remains unchanged.

2. Emergency Use Authorization for Monoclonal Antibody Bamlanivimab Revoked

Effective for dates of service on or after April 16, 2021, the U.S. Food and Drug Administration (FDA) revoked the emergency use authorization (EUA) that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults and certain pediatric patients. Based on its ongoing analysis of emerging scientific data, specifically the sustained increase of SARS-CoV-2 viral variants that are resistant to bamlanivimab alone resulting in the increased risk for treatment failure, the FDA has determined that the known and potential benefits of bamlanivimab, when administered alone, no longer outweigh the known and potential risks for its authorized use. Therefore, the agency determined that the criteria for issuance of an authorization are no longer met and has revoked the EUA.

More information can be found in the FDA news release on the subject.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (12); immun cd (1, 3)

3. CCS Service Code Groupings Policy Update

The following codes will be added to or end-dated from the California Children's Services (CCS) Service Code Groupings (SCGs):

Added Codes

Effective Date Codes SCGs
January 1, 2021 Proprietary Laboratory Analyses (PLA) codes 0001A, 0002A, 0011A, 0012A and 0031A 01, 02
January 1, 2021 CPT® codes 94726 and 94729 01
January 1, 2021 CPT code 92523 05

End-Dated Codes

Effective Date CPT Codes SCGs
January 1, 2021 76970, 78135, 94250, 94400, 94750 and 94770 01
January 1, 2021 32405 and 81545 02
January 1, 2021 92585 and 92586 01, 04, 05, 06

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (6, 14, 23, 24, 28, 32, 34, 36, 37)

4. New Provider Type: Tribal Federally Qualified Health Centers

Effective for dates of service on or after January 1, 2021, State Plan Amendment (SPA) 20-0044 establishes Tribal Federally Qualified Health Centers (Tribal FQHCs) as a new Medi-Cal provider type.

Under Section 1905(l)(2)(B) of the Social Security Act, outpatient health care programs operated by a tribe or tribal organization under the Indian Self-Determination and Education Assistance Act (ISDEAA), Public Law 93-638, are eligible to enroll as a Tribal FQHC in Medi-Cal. Tribal FQHCs provide covered primary care clinic services to Medi-Cal patients. Tribal FQHC services may be provided in a clinic or off site by tribal providers and non-tribal providers that are contractors of the Tribal FQHC. Reimbursement for Tribal FQHCs is through an Alternative Payment Methodology (APM), which is set at the federal Indian Health Service All-Inclusive Rate (AIR).

Tribal health clinics operating under the authority of the ISDEAA may request designation as a Tribal FQHC by completing an Elect to Participate” Indian Health Services Memorandum of Agreement (IHS/MOA) and Tribal Federally Qualified Health Center (FQHC) (form DHCS 7108).

New Provider Manual Sections

Program policy and billing code information are included in the new Tribal Federally Qualified Health Centers (Tribal FQHCs) and Tribal Federally Qualified Health Centers (Tribal FQHCs): Billing Codes sections of the appropriate Part 2 Medi-Cal provider manuals.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Community-Based Adult Services
tribal fqhc (1–19); tribal fqhc cd (1–12)
Part 1 prog (15)

5. Select Hepatitis B Code Changes for Vaccines for Children Program

Effective for dates of service on or after June 1, 2021, Vaccines for Children (VFC) Program CPT® codes 90740 (hepatitis B vaccine [HepB], dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use) and 90746 (hepatitis B vaccine [HepB], adult dosage, 3 dose schedule, for intramuscular use) have updated. The minimum age for CPT code 90740 is dropped from 20 to 18 and modifier SL (state-supplied vaccine) is added as an allowable modifier. CPT code 90746 is not billable for VFC.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Obstetrics
Rehabilitation Clinics
modif used (5); vaccine (6, 8)
Clinics and Hospitals
General Medicine
epsdt chdp school (8); modif used (5); vaccine (6, 8)

6. Gonorrhea Treatment Update for Family PACT and Medi-Cal

Effective for dates of service on or after June 1, 2021, the Department of Health Care Services (DHCS) is updating the treatment of uncomplicated gonorrhea in adolescents and adults for Family Planning Access, Care and Treatment (Family PACT) and Medi-Cal programs in accordance with the Centers for Disease Control and Prevention (CDC) guidelines titled Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (26, 27)
Family PACT ben grid (35, 36, 38–40); clinic (3)

7. BCCTP Applicants Granted Presumptive Eligibility

In the continued effort to align all Presumptive Eligibility (PE) Programs, Breast and Cervical Cancer Treatment Program (BCCTP) applications granted PE will populate in the Medi-Cal Eligibility Data System (MEDS) with an automated termination date of the end of the following month. As soon as the applicant fulfills the requirement to apply for full-scope Medi-Cal benefits from their county, this termination date will drop off and they will continue in PE until BCCTP makes the continuing eligibility decision. Also, the plastic Benefits Identification Card (BIC) will be issued when BCCTP makes the continuing eligibility decision. The “Confirmation Document” that is generated when Every Woman Counts (EWC) and Family Planning, Access, Care and Treatment (Family PACT) providers submit a BCCTP Enrollment Application should be used to obtain services by Medi-Cal providers during the PE period.

Providers are expected to hand-deliver, email or mail out to a BCCTP applicant, the “Confirmation Document” and the “Directions to Apply for Medi-Cal” that are generated together when the application is submitted. The “Confirmation Document” tells the applicants if they were granted PE and gives them their BIC number so they can obtain services. The “Directions of Apply for Medi-Cal” explains what the applicants must do in order for their benefits to continue beyond the end of the following month and serves as a notification that the benefits will terminate if they do not comply.

Questions concerning BCCTP PE should be sent to BCCTP@dhcs.ca.gov.

8. Assessment and Intervention CPT Codes Are no Longer PE4PW Benefits

Effective for dates of service on or after June 1, 2021, the following CPT® codes for health and behavior assessments and interventions are no longer benefits under the Presumptive Eligibility for Pregnant Women (PE4PW) program:

CPT Code Description
96156 Health behavior assessment, or re-assessment (for example, health-focused clinical interview, behavioral observations, clinical decision making)
96158 Health behavior intervention, individual, face-to-face; initial 30 minutes
96159 Health behavior intervention, individual, face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96164 Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes
96165 Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
96168 Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96170 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
96171 Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum bill (11, 12)

9. Changes to Dialysis Codes

Effective for dates of service on or after June 1, 2021, HCPCS codes S9335 (home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment [drugs and nursing services coded separately], per diem) and S9339 (home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment [drugs and nursing visits coded separately], per diem) are new Medi-Cal benefits.

Also effective for dates of service on or after June 1, 2021, the following local dialysis codes are terminated:

Code             Description                                                                                                                                                                                                    
Z6012       Home training dialysis, including routine laboratory charges
Z6014       Home training dialysis only
Z6030       Home dialysis (peritoneal or hemodialysis), including laboratory, support services, routine injections, and home dialysis supplies on a monthly basis
Z6042       Home training dialysis only (CMS approved)

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
dial chr (1–5, 8, 12)
General Medicine dial chr (1–5, 8, 12); dial end (2, 3, 5)

10. Consent for Psychiatric Collaborative Care Management Services

Effective June 1, 2021, prior to commencement of psychiatric collaborative care management services, the beneficiary must give the billing practitioner permission to consult with relevant specialists, which would include conferring with a psychiatric/addiction medicine consultant. Consent may be verbal (written consent is not required) but must be documented in the medical record. For information regarding definitions of episode of care and the care team members, refer to the CPT® book.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (31)

11. Clinical Laboratory Rates Triennial Update

Effective retroactively for dates of service on or after July 1, 2020, reimbursement rates for various clinical laboratory services have been updated.

In accordance with Assembly Bill 1494 (Chapter 28, Statutes of 2012) and the Welfare and Institutions Code (W&I Code), section 14105.22(3)(D), the Department of Health Care Services (DHCS) has developed reimbursement rates based on the triennial weighted average third-party payer rate methodology.

The updated rate information for each impacted code is available on the Medi-Cal Rates page.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

12. TAR Requirements Replaced for PLA Service Targeted Genomic Sequence Analysis

Effective for dates of service on or after June 1, 2021, the Treatment Authorization Request (TAR) requirements for Proprietary Laboratory Analyses (PLA) code 0037U (targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden) are replaced.

A TAR requires documentation of any one of the following criteria:

  • For ovarian, fallopian tube or primary peritoneal cancer:
    • The patient has been treated with two or more chemotherapies, or

    • The patient is experiencing complete or partial response to first-line platinum-based chemotherapy.

  • For Metastatic Castration-Resistant Prostate Cancer (MCRPC):
    • The patient has been treated with androgen receptor-directed therapy and a taxane-based chemotherapy.

  • For breast cancer:
    • The patient has HER2-negative metastatic breast cancer and has been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic setting.

    • The patient has HER2-negative locally advanced or metastatic breast cancer.

  • For metastatic pancreatic adenocarcinoma:
    • The patient’s disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen.
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
prop lab (9, 10)

13. Medi-Cal Rx Subscription Service and Pharmacy Service Representative Phone Campaign

In preparation for the eventual transition of pharmacy claim administration to Medi-Cal Rx, the Medi-Cal Rx Subscription Service (MCRxSS) is available and the Pharmacy Service Representative Phone Campaign has been activated for all Medi-Cal Rx providers, including pharmacies, prescribers and their staff.

Medi-Cal Rx Subscription Service

The MCRxSS is a free service that provides the latest Medi-Cal Rx news, including upcoming training and outreach events. Current Medi-Cal providers, pharmacies, prescribers and their staff are encouraged to sign up for MCRxSS to stay informed of the latest pharmacy news. Subscribers will receive subject-specific emails for urgent announcements and other updates shortly after they are posted to the Medi-Cal Rx website. Individuals can sign-up for this service at the following address on the MCRxSS sign up page on the DHCS website.

Pharmacy Service Representative Phone Campaign

Pharmacy Service Representatives (PSRs) will be reaching out to prescribers via a phone call to introduce the new Medi-Cal Rx website and its available resources. If you are a prescriber and have started the User Administration Console (UAC) registration process, but have not completed it, please anticipate a phone call from a PSR to assist and answer questions. The PSRs will provide guidance on how to start registration for the secure provider portal and inform prescribers of available training and resources for Medi-Cal Rx.

14. Medi-Cal Rx Pharmacy Provider and Prescriber Readiness Survey

How do you and your peers currently conduct business for Medi-Cal Pharmacy Claims?

In preparation for the eventual transition of pharmacy claim administration to Medi-Cal Rx, the Medi-Cal Rx Education & Outreach Team would love to hear from you! The results of the Medi-Cal Rx Pharmacy Provider & Prescriber Readiness Survey will be used to tailor our training offerings for Medi-Cal Rx to ensure you are prepared for the upcoming transition. The information you provide is confidential and will be used only for future training.

15. Updated Rates for Select Physician Administered Drugs

Effective for dates of service on or after January 1, 2021, rates are updated for claims billed with HCPCS code J3490 (unclassified drugs) and modifier U6 (levonorgestrel) or U8 (medroxyprogesterone acetate).

Procedure Code with Modifier Description Rate
J3490 U6 Levonorgestrel, 1.5 mg $13.85
J3490 U8 Medroxyprogesterone acetate, 150 mg $64.61

Providers should refer to the Medi-Cal Rates page of the Medi-Cal website for general rates information.

16. Billing Reminder for “Time in Attendance” For Anesthesia Obstetric

As directed in the Anesthesia Provider Manual section, “time in attendance” is the time when the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) monitors the patient receiving neuraxial labor analgesia, and the anesthesiologist or CRNA is readily and immediately available in the labor or delivery suite.

For additional details regarding billing “time in attendance”, visit: the Anesthesia provider manual section.

17. Get the Latest Medi-Cal News: Subscribe to MCSS Today

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

  2. Enter your email address and ZIP code and select a subscriber type

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

18. Provider Manual Revisions



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