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Medi-Cal Update

Clinics and Hospitals | September 2021 | Bulletin 564

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1. Manual Adjudication of Presumptive Eligibility Aid Codes Within the Same Month of Eligibility

Background

Qualified Providers (QPs) who have attempted to enroll individuals in another Presumptive Eligibility (PE) program when the individual is currently active on the COVID-19 Uninsured Group Program (aid code V2) are receiving a response that the individual currently has Medi-Cal eligibility. QPs are unable to enroll individuals in a more beneficial Presumptive Eligibility (PE) program aid code where benefits are not limited to COVID-19 related services. This limitation has created issues in accessing care for individuals who should be receiving services beyond COVID-19 related services.

In addition, federal guidance allows retroactive eligibility for V2 back to April 8, 2020. Currently, the COVID-19 Uninsured Group Program portal does not allow for retroactive eligibility requests.

Interim Process

Effective immediately and continuing until further guidance, QPs are instructed to send the appropriate application information to the Department of Health Care Services (DHCS) when the QP is unable to enroll an individual in another PE aid code within the same month of eligibility as outlined in the following scenarios.

For the Child Health and Disability Prevention (CHDP) Gateway Program

Scenario 1: The individual is currently enrolled in V2 and the QP attempts to process a CHDP Program application through the portal. However, the QP receives a denial eligibility response for the CHDP Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on CHDP Gateway Program requirements. If the QP determines that the individual is eligible for the CHDP Gateway Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed CHDP Gateway Program Application (DHCS 4073)

  • Copy of the denial eligibility response showing the CHDP Gateway Program could not be approved due to other PE coverage

  • Client Index Number (CIN)

  • The new CHDP aid code in which the individual should be enrolled

For the Hospital Presumptive Eligibility (HPE) Program

Scenario 2: The individual is currently enrolled in V2 and the QP attempts to process a HPE Program application through the portal. However, the QP receives a denial eligibility response for the HPE Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on HPE Program requirements. If the QP determines that the individual is eligible for the HPE Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed HPE Program Application (DHCS 7022)

  • Copy of the denial eligibility response showing the HPE Program could not be approved due to other PE coverage

  • CIN

  • The new HPE aid code in which the individual should be enrolled

For the Presumptive Eligibility for Pregnant Women (PE4PW) Program

Scenario 3: The individual is currently enrolled in V2 and the QP attempts to process a PE4PW Program application through the portal. However, the QP receives a denial eligibility response for the PE4PW Program because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on PE4PW Program requirements. If the QP determines that the individual is eligible for the PE4PW Program, the QP should send a secure email to PE@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the email body or as attachments:

  • Copy of PE4PW Program Application (MC 263)

  • Copy of the denial eligibility response showing the PE4PW Program could not be approved due to other PE coverage

  • CIN

  • The new PE4PW aid code in which the individual should be enrolled

For the Breast and Cervical Cancer Treatment Program (BCCTP)

Scenario 4: The individual is currently enrolled in V2 and the QP attempts to process a BCCTP PE application through the portal. However, the QP receives a denial eligibility response for the BCCTP PE because the individual is currently enrolled in V2.

Action: The QP should complete a manual determination based on BCCTP PE requirements. If the QP determines the individual is eligible for the BCCTP PE, the QP should send a secure email to BCCTP@dhcs.ca.gov with “Request to Overlay V2” in the email subject line and include the following information/documentation in the body of the email, or as attachments:

  • Completed BCCTP Application (MC 210BC)

  • Copy of the denial eligibility response showing BCCTP could not be approved due to other PE coverage

  • CIN

  • The new BCCTP PE aid code in which the individual should be enrolled

For the COVID-19 Uninsured Group Program

Scenario 5: The individual was previously enrolled in another PE aid code for the month and the QP attempts to process a COVID-19 Uninsured Group Program application through the portal in the same month. However, the QP receives a denial eligibility response for V2 because the individual was previously enrolled in another PE aid code within the same month.

Action: The QP should complete a manual determination based on COVID-19 Uninsured Group Program requirements. If the QP determines the individual is eligible for V2, the QP should send a secure email to COVID19Apps@dhcs.ca.gov with “Request to Overlay PE Aid Code” in the email subject line and include the following documentation:

  • Completed COVID-19 Uninsured Group Program Application (MC 374)

  • Copy of the denial eligibility response showing V2 could not be approved due to other PE coverage

  • CIN

  • Name of QP’s organization

  • QP’s National Provider Number (NPI)

During the interim process, DHCS will manually process the application referrals from QPs and provide a response to the provider via secure email. QPs should note DHCS will not process incomplete application referrals. If further information is needed, DHCS will reach out to the QP.

Once the QP receives confirmation from DHCS that the PE program application has been processed and approved, QPs should contact the individual regarding their approval into the new PE program and obtain an eligibility response for the individual.

Additionally, providers are to submit their claims for processing using the appropriate billing exception code. Refer to CMS-1500 Submission Timeliness Instructions in Part 2 of the Medi-Cal Provider Manual for further instructions. If your claim is denied for timeliness or eligibility, an Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. Claims re-processed by EPC are still subject to all edits and audits as governed by the Medi-Cal program and could be denied for a reason other than timeliness or eligibility. Providers may submit a Claims Inquiry Form (CIF) within six months of the new Remittance Advice Details (RAD) date or you may submit an Appeal Form (90-1) within 90 days of the new RAD date. For CIF completion instructions, please refer to the CIF Completion and CIF Special Billing Instructions sections in the appropriate Part 2 manual or on the Medi-Cal Providers website. For Appeal Form (90-1) completion instructions, please refer to the Appeal Form Completion section in Part 2 of the Medi-Cal Provider Manual.

Questions

  • Questions concerning the CHDP Gateway, HPE, or PE4PW Programs should be sent to PE@dhcs.c.agov.

  • Questions concerning BCCTP PE should be sent to Nancy Ojeda at BCCTP@dhcs.ca.gov.

  • Questions concerning the COVID-19 Uninsured Group Program should be sent to COVID19Apps@dhcs.ca.gov.

  • For billing or payment questions, providers may call the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday.

2. 2021 HCPCS/CPT® Q4 Update

The 2021 Quarter 4 updates to Healthcare Common Procedure Coding System (HCPCS) codes and Current Procedural Terminology – 4th Edition (CPT) codes are available in the 2021 HCPCS Q4 Policy PDF. These additions, changes and deletions are effective October 1, 2021.

Only those codes representing current and past Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) benefits are included in the list of updates. Please refer to the appropriate code books for complete descriptions of these codes.

Further manual page updates will be released in a future Medi-Cal Update.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
AIDS Waiver Program modif app (23, 24)
Audiology and Hearing Aids
Durable Medical Equipment
Orthotics and Prosthetics
cal child ser (27); modif app (23, 24); tax (12)
Chronic Dialysis Clinics blood (5, 7, 12–15); cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24)
Clinics and Hospitals
General Medicine
cal child ser (27); chemo drug a-d (3, 31); chemo drug e-o (13–16, 27-30, 36); chemo drug p-z (23, 25, 45); fam planning (5, 9); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29); once (1); presum bill (16); prop lab (30, 59–61); surg integ (4); tar and non cd0 (3, 34–39)
Family PACT (Policies, Procedures and Billing Instructions) ben fam (12); ben grid (3, 45); clinic (8, 20, 22); drug (3, 6, 7)
Heroin Detoxification tax (12)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Therapies
Vision Care
cal child ser (27); modif app (23, 24)
Inpatient Services cal child ser (27); tar and non cd0 (3, 34–39)
Long Term Care tar and non cd0 (3, 34–39)
Obstetrics cal child ser (27); fam planning (5, 9); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29); once (1); presum bill (16); prop lab (30, 59–61); tar and non cd0 (3, 34–39)
Pharmacy blood (5, 7, 12–15); cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (39); inject drug n-r (17–20); inject drug s-z (18, 19); presum bill (16); tax (12)
Psychological Services cal child ser (27)
Rehabilitation Clinics cal child ser (27); immun (16–24); inject cd list (2, 4, 5, 7, 9, 13, 16–18, 20, 23, 26); inject drug a-d (35, 45, 47); inject drug e-h (41); inject drug n-r (17–20); inject drug s-z (18, 19); modif app (23, 24); non ph (10, 12–15, 29)

3. Maximum Doses of Palivizumab Increased for 2021–2022 RSV Season

Effective for dates of services on or after August 19, 2021 and continuing for the 2021–2022 respiratory syncytial virus (RSV) season only, a Treatment Authorization Request(TAR) for additional doses of Palivizumab (CPT® code 90378 [respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each]) outside of a normal RSV season should be accompanied by county RSV positivity data for the time period reflecting the administered dose, confirming applicable RSV PCR and/or antigen positivity rates consistent with values seen during typical past RSV seasons. Additional information regarding county RSV positivity data can be found below.

Resources:

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (60, 62)

4. CCS Service Code Groupings Policy Update

The following codes will be added to the California Children's Services (CCS) Service Code Grouping (SCG) 02:

Added Codes

Effective Date Codes
April 1, 2021 HCPCS codes C9072, C9270 J1554, J1557, J1561, J1568, J1572, J1575, Q4087, Q4091, Q4092
June 1, 2021 HCPCS code J1569, Q4088

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.

Additionally, the Hierarchical Ingredient Code List (HICL) is updated for both CCS and Genetically Handicapped Persons Program (GHPP).

Code Updates

Effective Date Added/End-Dated Codes
April 1, 2021 Added CPT® codes 46773, 47149
April 1, 2021 End-Dated CPT codes 41391, 41762, 41763, 41764, 41798, 41855, 43712, 45354, 45734, 46208
June 1, 2021 Added CPT codes 41796, 45891

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims that were appropriately submitted, but erroneously paid based on previously published SCG and HICL information.

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 sar (8, 9); cal child ser (1, 26, 27); genetic (10, 11)

5. New Billable Services for Podiatrists

Effective retroactively for dates of service on or after January 1, 2020, the following CPT® codes are reimbursable for services rendered by a podiatrist:

CPT Code Description
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45–59 minutes of total time is spent on the date of the encounter
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60–74 minutes of total time is spent on the date of the encounter
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30–39 minutes of total time is spent on the date of the encounter
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40–54 minutes of total time is spent on the date of the encounter
99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient’s hospital floor or unit
99238 Hospital discharge day management; 30 minutes or less
99239 Hospital discharge day management; more than 30 minutes
99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family
99245 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family
99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit
99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit
99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function
99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit
99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit
99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit
99315 Nursing facility discharge day management; 30 minutes or less
99316 Nursing facility discharge day management; more than 30 minutes
99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver
99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver
99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver

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 appropriation and 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.

6. Radiology Codes 74261 thru 74263 are Now Medi-Cal Benefits

Effective for dates of service on or after October 1, 2021, CPT® codes 74261 (computed tomographic [CT] colonography, diagnostic, including image postprocessing; without contrast material), 74262 (computed tomographic [CT] colonography, diagnostic, including image postprocessing; with contrast material[s] including non-contrast images, if performed) and 74263 (computed tomographic [CT] colonography, screening, including image postprocessing) are added as Medi-Cal benefits.

CPT codes 74261 and 74262 are diagnostic billing codes and will not be reimbursable if billed for screening purposes. CPT code 74263 is to be used to bill for screening purposes only and is restricted to individuals between 45 and 75 years of age. ICD-10-CM code z12.11 is required on the claim to bill with this code. Annual screening is not recommended for ages 76 through 85 years old, however United States Preventive Service Task Force supports medical review to allow screening for colorectal cancer in this age group on a case by case. A Treatment Authorization Request (TAR) is required for these radiological services.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (38); tar and non cd7 (6)
Inpatient Services tar and non cd7 (6)

7. Home Dialysis Codes Added to Medi-Cal Provider Manual

Home dialysis 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) became Medi-Cal benefits on June 1, 2021. They are located in the following Provider Manual sections:

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
dial chr (2); dial end (2)
General Medicine dial end (2); non ph (11)
Obstetrics
Rehabilitation Clinics
non ph (11)

8. Mircera Injection for Non-ESRD Use is Now a Medi-Cal Benefit

Effective for dates of service on or after October 1, 2021, methoxy polyethylene glycol-epoetin beta (Mircera®) is no longer limited to patients with End Stage Renal Disease (ESRD). Mircera can be billed using the following HCPCS codes:

  • J0887 (injection, epoetin beta, 1 microgram, [for ESRD on dialysis])

  • J0888 (injection, epoetin beta, 1 microgram, [for non-ESRD use])

For more information about Medi-Cal’s billing policies and instructions for Mircera, refer to the appropriate Part 2 Provider Manual section.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (8); inject drug e-h (33, 34); inject drug i-m (35–39)

9. Radiology Reimbursement Rate Are Updated Retroactively

Effective retroactively for dates of service on or after January 1, 2021, radiology reimbursement rates are updated.

In pursuant to Senate Bill 853 (Chapter 717, Statutes of 2010), the Department of Health Care Services (DHCS) has adjusted Medi-Cal reimbursement rates for radiology services so they do not exceed 80 percent of the corresponding Medicare rate.

The updated radiology reimbursement rates are available on the Medi-Cal Rates page.

An Erroneous Payment Correction (EPC) will be implemented to reprocess 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 paid base on the previous Medi-Cal rate. 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.

10. Upcoming Changes to Outpatient Claims Processing and Provider Identifiers

To implement provisions of the Patient Protection and Affordable Care Act (ACA)(Public Law 111-148, Section 1104), information will be accepted in the Other fields (Boxes 78 and 79) on the UB-04 claim and the equivalent loops used electronically. The appropriate provider type qualifier will be entered in the first small field for rendering (82), ordering/referring/prescribing (DN) and other operating (ZZ) providers. The National Provider Identifier (NPI) will be entered in the second, larger field labeled NPI. The ACA also requires an attending individual provider (Type 1 NPI) on all outpatient UB-04 and electronic claims. The Attending field (Box 76) and loop 2310A will be mandatory. The Operating field (Box 77) will be used for claims with surgery codes. When entering rendering, referring and operating providers, the individual (Type 1 NPI) must be used.

For detailed information, refer to the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual for paper claim instructions and the ANSI ASC X12 TR3 for electronic claim instructions as these are the national standards. The supplemental provider boxes and equivalent electronic loops of boxes 76-79 will be used for the few atypical providers that do not have an NPI. More specific instructions related to this update, including the effective date, will be published in future News articles, Provider Manuals, and Medi-Cal Updates.

11. Frequency Limit Updated for Evaluation and Management Service

Effective for dates of service on or after April 1, 2021, the maximum frequency limit for CPT® code 99417 (prolonged office or other outpatient evaluation and management service[s] beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time) is updated from ten units per day to four units per day.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (5)

12. Improvements to Transaction Services

Beginning September 20, 2021, in an effort to continue to modernize and improve the user experience for Medi-Cal Provider website users, the look and feel of several webpages will be updated.

Note: Functionality is not changing. These updates refresh the look and feel only.

This release includes user interface updates to applications within Transaction Services and several webpages outside of Transaction Services.

A complete list of enhancements, updates and additional website changes can be viewed within the Medi-Cal Provider Website Release Change Log (PDF file size 69 KB).

The next release will include all of the remaining Transaction Services updates, as well as updating and reorganizing the Transaction Services Menu page for a better user experience.

Providers are also encouraged to subscribe to the free Medi-Cal Subscription Service (MCSS). The MCSS allows each subscriber to choose and tailor both the subject matters and types of communications they wish to receive from the Medi-Cal Program.

13. National Correct Coding Initiative Quarterly Update for October 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 October 1, 2021.

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

14. November 2021 Virtual Claim Assistance Room (CAR) Event

Receive free one-on-one billing assistance at our virtual Claims Assistance Room (CAR) event scheduled for the month of November.

There are multiple morning and afternoon sessions available. Providers must register through the Medi-Cal Learning Portal Event Calendar.

Reminder: First time users must complete a one-time registration. For instructions on how to enroll in one of these sessions, use the link to the short video in the descriptive text on the “Provider Seminars and Webinars” tile on the Medi-Cal Learning Portal home page.

Providers are encouraged to bring their more complex billing issues and receive individual assistance from a provider field representative.

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

15. 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.

16. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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