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Medi-Cal Update

Clinics and Hospitals | June 2021 | Bulletin 561

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1. New Telehealth Code Added to EWC for FQHC/RHC Providers

Effective retroactively for dates of service on or after March 4, 2020, the Every Woman Counts Program (EWC) has added HCPCS code G0071 as a benefit to align with the Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus (COVID 19) guidelines.

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. EWC services rendered using telehealth modalities and the above HCPCS code should be billed with an appropriate ICD-10-CM code(s) listed in tables 1a, 1b, 2a and 2b in the Every Woman Counts section of the Provider Manual.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (34–38)

2. 2021 HCPCS Q3 Update

The 2021 Quarter 3 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the HCPCS Policy Updates PDF. Effective dates for these code additions and deletions vary and are listed in the Policy PDF, however, system implementation for these codes will not be processed until on or after July 1, 2021.

Only those codes representing current and past Medi-Cal benefits are included in the list of updates. Please refer to the HCPCS Level I and II code books for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14)
Clinics and Hospitals
General Medicine
chemo drug e-o (22–24, 28–30, 37, 38); chemo drug p-z (18, 19, 24, 25, 44–46); immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30); once (1); presum bill (16); radi dia (27–29); radi nuc (7); tar and non cd0 (33, 34)
Inpatient Services tar and non cd0 (33, 34)
Obstetrics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30); once (1); presum bill (16); radi dia (27–29); radi nuc (7); tar and non cd0 (33, 34)
Pharmacy immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); presum bill (16)
Rehabilitation Clinics immun (16–18, 20–22, 28, 29, 34); immun cd (1, 4); inject cd list (4, 5, 9, 10, 16, 17, 19, 22, 23, 26); inject drug a-d (35–38, 42–45, 68); inject drug e-h (39–41); inject drug i-m (22, 23, 26); inject drug n-r (27); modif used (4, 6, 12–14); non ph (10, 12–16, 27, 28, 30)

3. Policy Updates for Opioid Use Disorder Emergency Department Treatment

Effective retroactively for dates of service on or after January 1, 2021, policy is updated for HCPCS code G2213 (initiation of medication for the treatment of opioid use disorder in the emergency department setting, including assessment, referral to ongoing care, and arranging access to supportive services).

The frequency limit for code G2213 is updated to once per day, any provider. Modifier UD is no longer allowed.

Effective retroactively for dates of service on or after January 1, 2021, modifiers 24 and 25 are allowed when billing HCPCS code G2213.

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, but erroneously denied due to use of modifier 24 or 25. No action is required of providers.

For more information regarding Medi-Cal’s policy for HCPCS code G2213, refer to the Evaluation & Management (E&M) section of the appropriate Part 2 manual.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (10, 37, 38); modif used (13)

4. Updates to Drug and Alcohol Use Screening and Counseling

Effective for dates of service on or after July 1, 2021, the following HCPCS codes G0442, G0443 and H0050 are updated as follows:

HCPCS Code Description Update
G0442 Annual alcohol misuse screening, 15 minutes The minimum age has changed from age 18 to age 11.
G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes The benefit status has changed from a Medi-Cal benefit to a non-benefit.
H0050 Alcohol and/or drug services, brief intervention, per 15 minutes The benefit status has changed from a non-benefit to a Medi-Cal benefit.

Effective retroactively for dates of service on or after June 9, 2020, HCPCS code H0049 (alcohol and/or drug screening) is updated as follows:

HCPCS Code Description Update
H0049 Alcohol and/or drug screening The benefit status has changed from a non-benefit to a Medi-Cal benefit. HCPCS code H0049 should be used for drug use screening only.

HCPCS codes H0049 and H0050 are reimbursable “by report.” An attachment documenting the services delivered must be submitted with claims for H0049 and H0050. For information regarding documentation requirements for H0049 and H0050, refer to the Evaluation & Management section of the appropriate Part 2 Provider Manual.

See article Retroactive Policy Change for Drug Use Screening for additional information on billing instructions for H0049.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (9, 10, 30–33, 40); prev (2, 11, 17); non ph (9, 25)
Obstetrics eval (9, 10, 30–33, 40); non ph (9, 25)
Rehabilitation Clinics non ph (9, 25)

5. Retroactive Policy Change for Drug Use Screening

Effective retroactively for dates of service on or after June 9, 2020, HCPCS code H0049 (alcohol and/or drug screening) is available as a Medi-Cal benefit. HCPCS code H0049 should be used for drug use screening only.

Providers Who Have Not Previously Billed, But Have Applicable Claims

The Department of Health Care Services (DHCS) acknowledges that there may be claims for this retroactive benefit, with dates of service that are past the timeliness limits that Medi-Cal requires providers to abide by (see the Claim Submission and Timeliness Overview section of the Part 1 Provider Manual for more information). To accommodate affected providers, DHCS is allowing for retroactive billing for claims with dates of service that exceed the six-month billing limit, so long as all of the following criteria are met:

  • Providers must bill using a paper claim form (CMS-1500 or UB-04);

  • Claims for HCPCS code H0049 that are past the timeliness rule, must use delay reason code 11, and list “retroactive policy change” as the justification;
  • Applicable claims must be submitted within 90 days of this publication. The last day claims submitted in this manner will be accepted, is September 14, 2021. Claims submitted after this period will be denied.

Claims are still subject to typical edits and audits. Providers are responsible for appropriate claims follow-up if applicable. Additional policy surrounding HCPCS code H0049 can be found in the Evaluation & Management (E&M) section of the appropriate Part 2 Provider Manual. If providers have claims with dates of service within the six-month billing limit, they may bill as they traditionally would.

Providers Who Have Previously Billed

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims that were already appropriately submitted based on the effective date and now-published provider manual policy, but were erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. For those previously and correctly submitted claims, no additional action is required by the provider.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (9, 10, 30–33); prev (11); non ph (9, 25)
Obstetrics eval (9, 10, 30–33); non ph (9, 25)
Rehabilitation Clinics non ph (9, 25)

6. Policy Update for Specific Chemotherapy and Injection HCPCS Codes

Effective for dates of service on or after June 1, 2021, the Department of Health Care Services (DHCS) has updated the policies for Healthcare Common Procedure Codes (HCPCS) J9023, J9228 J9299 and Q5110 to include:

  • No Treatment Authorization Request (TAR) required for reimbursement

  • FDA approved indications

  • FDA approved dosages

Additional information regarding these HPCPS codes can be found in the updated manual sections located on the Medi-Cal Provider website.

7. Procedure Type and Benefit Status Updated for CPT Code 48160

Effective for dates of service on or after July 1, 2021, the obsolete procedure types B, 5 and 6, are terminated for CPT® code 48160 (pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells).

Also effective for dates of service on or after July 1, 2021, CPT code 48160 is a benefit for surgeons and assistant surgeons and requires a Treatment Authorization Request (TAR) for reimbursement.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
tar and non cd 4 (33); transplant (1–10, 12)

8. Medi-Cal Provider Website: Navigation Improvements to Publications Content

In an effort to improve the Medi-Cal Provider website user experience, the Department of Health Care Services (DHCS) will implement improvements to the organization and navigation to Provider Manuals, news articles, and Provider Bulletins. These changes will be available on July 12, 2021.

When selecting Publications from the header, the new landing page will contain the same content with a new look and feel. Medi-Cal Provider website users will be able to navigate to provider communities to access community-specific content or content merged from all communities. As a result, navigation among provider community-specific content requires fewer clicks and includes intuitive navigation to assist website users to locate the content they seek.

Website users will also be able to select search in the header and search Medi-Cal News and Provider Bulletins content only, similarly to how users can currently search Provider Manuals only.

Provider Bulletins will be more integrated within the Medi-Cal Providers website, as a normal webpage. This will assist in navigating between bulletins and other website content, while still maintaining the ability to print bulletins altogether or a specific article as needed.

9. Start of the Reporting Year (RY) 2023 Payment Error Rate Measurement (PERM) Cycle

The California Department of Health Care Services (DHCS) wishes to notify all California Medi-Cal providers of the start of the Reporting Year (RY) 2023 Payment Error Rate Measurement (PERM) by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to identify erroneous payments made in Medicaid and the Children’s Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress.

During RY 2023 PERM, Medicaid and CHIP Medi-Cal claims will be randomly selected for Medical Reviews for the fiscal year beginning July 1, 2021, and ending June 30, 2022. Your cooperation will help ensure that the payment measurement rate for PERM reviews are accurate and that California retains its much-needed federal match monies for the Medi-Cal program.

What if one of my claims is selected for the PERM?

If one of your Medi-Cal claims is selected for the PERM, you will receive a notification letter from DHCS letting you know you have been selected, and the CMS Review Contractor, (RC) NCI Information Systems, Inc., will be contacting you for medical records. The letter from DHCS will not contain patient specific information.

The RC will contact you via telephone to verify your contact information and, patient name. The RC will also arrange to send you an official request letter on CMS letterhead detailing what information is needed.

DHCS anticipates its notification letters will be sent out for the first quarter of sampled claims in late 2021. The RC may begin contacting quarter one providers in late 2021 or early 2022. A total of four quarters of claims will be selected for review during the PERM cycle so it is possible you may receive multiple requests at different times during the PERM process.

Am I obligated to submit medical records for the PERM?

Yes. One of the most common types of error findings are caused by providers failing to respond to requests for medical records. Another error finding frequently cited is submission of insufficient documentation.

To reduce error findings in PERM reviews and ensure that providers are compliant with State and federal regulations, DHCS would like to remind providers of the following:

  • Title 22 of the California Code of Regulations, Section 51476, states that, “each provider shall keep, maintain, and have readily retrievable, such records as are necessary to fully disclose the type and extent of services provided to a Medi-Cal beneficiary.” This includes medical records, orders, treatment authorization requests, and the time and date of service for each beneficiary.

  • Under Sections 1902(a)(27) and 2107 (b)(1) of the Social Security Act, CMS and their representatives have the authority to collect all documentation to support a Medicaid claim.

  • DHCS requires all enrolled providers to report changes to any information previously submitted as part of the provider enrollment application package, which includes the business address or phone number, within 35 days of the date of change.

  • Failure to respond to requests for medical records may result in suspension from the Medi-Cal program as per Welfare and Institutions Code (W&I), Section 14124.2(b)(1) and Section 14124.2.

Not only do error findings affect California’s PERM rate, but claims cited with error findings at the conclusion of the medical review are also considered improperly paid. Therefore, in accordance with W&I Section 14172.5, DHCS is authorized to recoup these payments. Providers that receive a demand for recovery of claim payments are urged to remit the demand amount as soon as possible.

Where can I find out more about PERM and my responsibility to participate?

You can find more information about PERM on the DHCS website:
https://www.dhcs.ca.gov/individuals/Pages/AI_MRB_PERM.aspx

You can find information about provider specific responsibility on the CMS PERM website:
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers

You may contact a member of the DHCS PERM Team with your questions at:
PERM@dhcs.ca.gov

10. National Correct Coding Initiative Quarterly Update for July 2021

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for dates of service on or after July 1, 2021.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

11. June 2021 Medi-Cal Provider Training Webinars

Provider Outreach and Education along with the Department of Health Care Services, is offering category-specific webinar sessions in June. Training categories offered will include the following:

  • Resources: June 1, 2021, and June 2, 2021

  • Long Term Care: June 10, 2021

  • Common Denials: June 15, 2021

  • Claims: June 23, 2021

  • Presumptive Eligibility Programs: June 29, 2021

A variety of courses will be offered in each of the training categories listed. Providers must register through the Medi Cal Learning Portal (MLP) Event Calendar. Providers will be able to print class materials and ask questions during the training sessions. To view the webinars, providers must have internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal Provider website.

For additional assistance, contact the Telephone Service Center (TSC) at 1-800-541-5555.

12. July 2021 Medi-Cal Provider Training Webinars

Beginning July 6, 2021, continuing throughout the month of July, Medi-Cal providers may participate in the following category-specific webinar sessions.

Categories offered will include the following:

  • Family PACT: July 6, 2021

  • Health Access Programs: July 8, 2021

  • Medical Services: July 13, 2021

  • Home Health Services: July 21, 2021

  • Specialty Programs: July 27, 2021

A variety of courses will be offered in each of the categories listed. Providers must register through the Medi-Cal Learning Portal (MLP) Event Calendar.

Providers will be able to print class materials and ask questions during the training sessions.

To view the webinars, providers must have internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal website.

For additional assistance, please contact the Telephone Service Center (TSC) at 1-800-541-5555.

13. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective April 1, 2021
NDC Labeler Code Contracting Company's Name
74527 Macrogenics, Inc.
Additions, effective October 1, 2016
NDC Labeler Code Contracting Company's Name
70121 Amneal Pharmaceuticals, LLC

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program      
General Medicine
Heroin Detoxification
Home Health Agencies/Home and
Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (18, 22)

14. 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.

15. Provider Manual Revisions



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