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Medi-Cal Update

Clinics and Hospitals | October 2021 | Bulletin 565

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1. Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Authorized for Certain Populations

Effective for dates of service on or after August 12, 2021, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorizations (EUA) for the Pfizer-BioNTech and Moderna COVID-19 vaccines to permit the administration of a third dose to certain individuals with compromised immune systems. For the most current direction regarding guidelines for use of these vaccines, including how to bill for the administration of a third dose, refer to the following COVID-19 vaccine web pages:

To assist providers, billing guidelines specific to administration of a third dose are published below.

Providers should note that all billing guidelines included below are only current as of the publication of this article.

General Policy

  • The third dose should be administered no earlier than 28 days following the two-dose regimen of the same vaccine to individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.

  • Age restrictions for use of the vaccine product are not changed with this update.

  • The policy for maximum allowable reimbursement is not changed with this update.

Pharmacy Claims

  • Use previously published National Drug Codes (NDC) associated with the Pfizer-BioNTech and Moderna COVID-19 vaccines to indicate the third dose in claims submitted both electronically and on paper. In addition,

    • When submitting electronic claims utilizing NCPDP D.0, NCPDP 1.2, or RTIP transactions, providers should use Submission Clarification Code (SCC) 7 to indicate that a third dose of a COVID-19 vaccine is being administered and billed.

    • When submitting hard copy claims, providers should enter either a 3 or 03 in the Fill Number field (Box 12) to indicate that the third dose is being administered and billed.

  • Batch (NCPDP 1.2) and paper claims (30-1) may be suspended upon submission until further system updates required to properly adjudicate those claims are implemented. Pharmacy providers will be informed when these system updates are implemented.

Medical and Outpatient Claims

  • Pfizer-BioNTech: Administration of a third dose must be indicated by using CPT® code 0003A.

  • Moderna: Administration of a third dose must be indicated by using CPT® code 0013A.

FDA Approval of Pfizer-BioNTech COVID-19 Vaccine

On August 23, 2021, the FDA formally approved the biologics license application (BLA) for Pfizer-BioNTech’s COVID-19 vaccine, commercially known as Comirnaty. As of the publication of this article, the FDA approval applies to the administration of the vaccine in individuals 16 years of age and older.

The original Pfizer-BioNTech COVID-19 vaccine EUA still remains in effect, however, and allows individuals 12 through 15 years of age to receive the Pfizer-BioNTech COVID-19 vaccine, and also allows for the administration of a third dose to certain immunocompromised individuals.

Medi-Cal’s policy regarding the Pfizer-BioNTech vaccine and the administration of the vaccine, with respect to the formal FDA approval of the Comirnaty product and the existing EUA, remains unchanged as of the original publication of this article. Providers should refer to the Pfizer-BioNTech COVID-19 Vaccine web page on the Medi-Cal Provider website for the most current billing guidelines that should be followed when submitting a claim to Medi-Cal for the administration of a Pfizer-BioNTech COVID-19 vaccine.

Additional Information

The NCPDP Payer Sheet is updated as of publication of this article. Provider manual updates reflecting these changes will be released in a future Medi-Cal Update.

This guidance is only effective for COVID-19 vaccines purchased by the federal government. At a future date, DHCS will provide an end date to this temporary policy and instruct providers on how they should bill for the reimbursement of provider purchased COVID-19 vaccines.

Providers with questions should contact the Telephone Service Center (TSC) Help Desk at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers should call 1-916-636-1200.

2. Supplemental Rate for Administration of COVID-19 Vaccine in Home Setting

General Policy

Effective for dates of service on or after June 8, 2021, Medi-Cal will reimburse providers an additional $35.00 per dose when administering a Coronavirus Disease 2019 (COVID-19) vaccine in the home of a Medi-Cal beneficiary who is unable to travel to a vaccination site. This supplemental rate is to be in addition to the $40.00 maximum allowable reimbursement currently in effect for each COVID-19 vaccine. Current reimbursement rates and billing instructions regarding each of the COVID-19 vaccines is located on the following web pages:

The supplemental Medi-Cal reimbursement is only applicable if the sole purpose of the visit is to administer a COVID-19 vaccine. The additional amount is not reimbursable if another service, separate from the administration of a COVID-19 vaccine, is provided in the same home on the same date of service. In the instance of another service being a part of the visit, Medi-Cal will only reimburse the COVID-19 vaccine administration based on the base maximum allowable reimbursement and will not apply the supplemental rate.

The supplemental home administration fee is designed to target Medi-Cal beneficiaries that have difficulty leaving the home to get the vaccine, which could mean any of these:

  • They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver

  • They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19

  • They are generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort

  • The patient is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home.

Detailed Policy

For dates of service between June 8, 2021, and August 23, 2021, if a provider administers the COVID-19 vaccine to more than one beneficiary in a single home on the same day, Medi-Cal will reimburse the additional $35.00 reimbursement only once per date of service in that home.

  • For example, if a provider administers a single-dose vaccine on the same date to two Medi-Cal patients in the same home, Medi-Cal will reimburse one payment of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. The total reimbursement in this scenario would be $115.00.

For dates of service on or after August 24, 2021, if the vaccine is administered to fewer than 10 Medi-Cal beneficiaries on the same day residing in the same home, Medi-Cal will reimburse up to a maximum of five times when multiple Medi-Cal patients are vaccinated in the same home.

  • For example, if a provider administers six vaccines to Medi-Cal patients in the same home, Medi-Cal will reimburse five payments of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. For a total reimbursement of $415.00.

Locations that can qualify as a patient’s home for the additional in-home payment amount, includes, but is not limited to, the following:

  • A private residence

  • Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)

  • An apartment in an apartment complex or a unit in an assisted living facility or group home

  • When the patient’s home has been made provider-based to a hospital during the COVID-19 Public Health Emergency (PHE)

However, the following locations are not considered “homes” that can qualify for the additional payment amount:

  • Communal spaces of a multi-unit living arrangement

  • Hospitals (except when the Medicare patient’s home has been made provider-based to a hospital during the COVID-19 PHE)

  • Skilled nursing facilities (SNFs), regardless of whether they are the patient’s permanent residence

  • Assisted living facilities participating in the CDC’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program

How to Bill

Medical and Outpatient providers should denote this additional service on the same claim as the vaccine administration, using HCPCS code M0201 (COVID-19 vaccine administration inside a patient’s home; reported only once per individual per date of service when only COVID-19 vaccine administration is performed at the patient’s home).

Pharmacy providers should denote this additional service on the same claim as the vaccine administration, using NDC 99999999995.

Providers who administered a COVID-19 vaccine in a beneficiary’s home but did not originally submit vaccine administration claims with this billing instruction are instructed to submit a separate claim for applicable dates of service.

Additional Information

Additional information regarding these updates can be found in the Immunizations section in Part 2 of the Medi-Cal Provider Manual.

3. 2021 HCPCS Q4 Update Additional Information Available

A previously published Medi-Cal Update added, changed and deleted Current Procedural Terminology – 4th Edition (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes for the 2021 Quarter 4 update, effective October 1, 2021. Additional manual pages reflecting these changes are now available.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
modif used (4, 12–16); surg integ (6)
Dialysis Clinics
Rehabilitation Clinics
modif used (4, 12–16)
Durable Medical Equipment
Therapies
ortho cd2 (5); ortho cd fre2 (1)
Orthotics and Prosthetics
Pharmacy
ortho auth pros (14, 15); ortho cd2 (5); ortho cd fre2 (1)

4. Updated Policy for Palivizumab for the 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, county RSV positivity data for the time period reflecting the administered dose of Palivizumab (CPT® code 90378 [respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each]) is no longer required to be accompanied with a Treatment Authorization Request (TAR) for doses submitted outside the time period of a typical RSV season such as 2019–2020. Additional information can be found below.

Resources:

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitations Clinics
immun (62, 64)

5. Revision to Medi-Cal Abortion Policies

Effective for dates of service on or after November 1, 2021, the Abortion section in the appropriate Part 2 Provider Manual section has been updated to ensure flexibilities exist for providing medically necessary abortion services during the COVID-19 Public Health Emergency (PHE) and to remove requirements for a Medicare denial for certain abortions services.

Additional information can be found in a previous article titled Important News about Women’s Health Services, published July 29, 2020, which was released in response to the federal preliminary injunction Civil Action No. TDC 20-1320.

The recent federal preliminary injunction Civil Action No TDC 20-1320 and associated policy changes will be addressed in a future Medi-Cal Update.

Provider Manual(s) Page(s) Updated
Clnics and Hospitals
General Medicine
Obstetrics
abort (4, 6–9)

6. Billing Instructions Updated for Contraceptive Patches

Effective for dates of service on or after October 1, 2021, HCPCS code J7304 (contraceptive supply, hormone containing patch, each) must be billed with modifier U1 for norelgestromin and ethinyl estradiol transdermal system (Xulane®) or U2 for levonorgestrel and ethinyl estradiol transdermal system (Twirla®).

HCPCS codes J7304U1 and J7304U2 have a maximum dispensing quantity of 52 patches that can be dispensed twice in a 12-month period. Both codes require a Treatment Authorization Request (TAR) for a third dispensing of the same product requested within a 12-month period.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after October 1, 2021, that were appropriately submitted based on the guidance published in this article, but erroneously denied because the system changes to support appropriate adjudication were not yet implemented. 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.

Provider Manual(s) Page(s) Updated
AIDs Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Durable Medical Equipment
Home Health Agencies/ Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (23, 24)
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (5, 9); modif app (23, 24); non ph (12, 24)
Family PACT ben fam (12); ben grid (3, 46); clinic (11, 12, 22); drug (3, 7)
Rehabilitation Clinics modif app (23, 24); non ph (12, 24)

7. New Contraceptive Vaginal Gel Added as Clinic Benefit for the Family PACT and Medi-Cal Programs

Effective for dates of service on or after July 1,  2021, contraceptive vaginal gel, Phexxi® (lactic acid, citric acid and potassium bitartrate), is a clinic benefit for the Family Planning, Access, Care and Treatment (Family PACT) and Medi-Cal programs. Phexxi is reimbursable under HCPCS code A4269 (contraceptive supply, spermicide [e.g., foam, gel], each) with modifier U5 for contraceptive vaginal gel.

HCPCS code A4269U5 is restricted to one box (12 single-use applicators) per dispensing and is limited to three dispensings per any 75-day period.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims with dates of service on or after July 1, 2021, to the implementation date of this policy. 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.

Provider Manual(s) Page(s) Updated
AIDs Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Durable Medical Equipment
Home Health Agencies/ Home and Community-Based Services
Local Educational Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (24)
Clinics and Hospitals
General Medicine
Obstetrics
fam planning (5, 13, 14); modif app (24); non ph (27)
Family PACT ben fam (5, 31); ben grid (2–8, 14, 16, 45); clinic (9); drug (3–5); drug onsite (1); prog stand (6)
Rehabilitation Clinics modif app (24); non ph (27)

8. New Pathology Benefits for Gene Analysis

Effective for dates of service on or after September 1, 2021, CPT® codes 81340, 81341 and 81342 are once-in-a-lifetime Medi-Cal benefits with an approved Treatment Authorization Request (TAR).

Code Description
81340 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction)
81341 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot)
81342 TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s)
Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics path bil (1)
Clinics and Hospitals
General Medicine
Obstetrics
path bil (1); path molec (43, 44); tar and non cd8 (8)
Inpatient Services tar and non cd8 (8)

9. Ferric Derisomaltose Iron Replacement Injection is a Medi-Cal Benefit

Effective for dates of service on or after November 1, 2021, HCPCS code J1437 (injection, ferric derisomaltose, 10 mg) is a Medi-Cal benefit.

Ferric derisomaltose (Monoferric®) is an iron replacement product indicated for the treatment of iron deficiency anemia in adult patients who have intolerance to oral iron, have had unsatisfactory response to oral iron or have non-hemodialysis dependent chronic kidney disease. The maximum dosage is 1,000mg/100 units.

A Treatment Authorization Request (TAR) is required for reimbursement.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (9); inject drug e-h (40, 41)

10. USPSTF Recommends Prediabetes and Type 2 Diabetes Screening and Tests

Effective for dates of service on or after November 1, 2021, the Preventive Services section of the appropriate Part 2 Provider Manual has been updated to align with recent U.S. Preventive Services Task Force (USPSTF) recommendations to screen and/or test eligible adults with prediabetes and type 2 diabetes.

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

11. Medi-Cal Rates Adjustment

Effective for dates of service on or after October 1, 2021, Medi-Cal rates have been adjusted to adhere to requirements mandated by the Centers for Medicare and Medicaid Services (CMS).

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

12. Updates to Facility Types for Outpatient Billing

Effective for dates of service on or after November 1, 2021, facility type code “02” (services provided or received through a telecommunication system) is no longer allowable on Medi-Cal claims. When billing for telehealth services, providers should report the Type of Bill code that most accurately reflects the type of facility submitting a claim for the service and report the appropriate claim frequency code as defined by the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual.

Additionally, several outpatient facility type definitions have been updated. Refer to the UB-04 Completion: Outpatient Services in the Part 2 Medi-Cal Provider Manual for updated definitions.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
medne tele (5); ub comp op (4, 5, 8)
AIDS Waiver Program
Chronic Dialysis Clinics
Community-Based Adult Services
Heroin Detoxification
Home Health Agencies/Home and
Community-Based Services
Hospice
Local Educational Agency
Multipurpose Senior Services Program
Rehabilitation Clinics
ub comp op (4, 5, 8)

13. ICD-10-CM Diagnosis Code Correction for Cystic Fibrosis

The ICD-10-CM diagnosis code for CPT code 81220 (CTFR [cystic fibrosis transmembrane conductance regulator] gene analysis; common variants [eg, ACMG/ACOG guidelines]) O09.00 thru O09.03 has been corrected to O09.00 thru O09.93.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
gene coun (4)

14. Updated TAR Criteria for Blinatumomab (Blincyto®)

Effective for dates of service on or after December 1, 2021, Treatment Authorization Request (TAR) requirements have been updated for Healthcare Common Procedure Code (HCPC) code J9039. For additional information regarding the policy for Blincyto, please refer to the Part 2 Provider Manual Section.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug a-d (20)

15. 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 October 1, 2021
NDC Labeler Code      Contracting Company's Name
65038Corium, Inc.
71921Florida Pharmaceutical Products, LLC
72664Vgyaan Pharmaceuticals
72730QED Therapeutics, Inc.
73059Shield Therapeutics
73317Aum Pharmaceuticals.
73606APL Sales I LLC
73607Amivas (US), LLC
74528Albireo Pharma, Inc.
75788Scynexis, Inc.
78206Organon, LLC
79802Kadmon Pharmaceuticals, LLC
81561Porton Biopharma Limited
  
Terminations, effective October 1, 2021
NDC Labeler Code      Contracting Company's Name
66621Rare Disease Therapeutics, Inc.
70720Tersera Therapeutics, LLC
89141Midatech Pharma US, Inc.
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 (15, 19–23)

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17. Provider Manual Revisions



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