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Medi-Cal Update

Chronic Dialysis Clinics | January 2021 | Bulletin 556

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1. DHCS Announces New Program to Enhance Hospital Capacity Amid COVID-19 Surge

On November 25, 2020, the Centers for Medicare & Medicaid Services (CMS) announced an expansion of the Hospital Without Walls initiative to include the Acute Hospital Care at Home program. The intent of this program is to increase hospital capacity by allowing patients to be seen outside of a traditional hospital setting, while also protecting patients to ensure that they are treated appropriately and safely in at-home settings during the COVID-19 public health emergency.

The Acute Hospital Care at Home program clearly differentiates the delivery of acute hospital care at home from more traditional home health services, which provides skilled nursing and other skilled care services at a beneficiary’s home. In contrast, the Acute Hospital Care at Home program is for patients who require acute inpatient admission to a hospital and require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis. Acute Hospital Care at Home services provide health care to acutely ill patients in their homes by using methods that include telehealth, remote monitoring, and regular in-person visits by nurses. Hospitals interested in this program need to apply directly with CMS for the waiver at the Acute Hospital Care at Home Individual Waiver webpage to submit the necessary information to ensure they meet the program’s criteria to participate. CMS will closely monitor the program, to safeguard beneficiaries, by requiring hospitals to report quality and safety data to CMS on a frequency that is based on their prior experience with the Hospital At Home model.

General acute care hospitals (GACH) are required to coordinate with the California Department of Public Health (CDPH) to operate under the state's emergency preparedness or pandemic plan during this PHE to help meet surge needs in their community. Hospitals must meet state licensure requirements for GACHs and receive program flexibility from CDPH for any requirement that will be met using an alternative method as indicated under the Program Flex heading. In addition to receiving approval from CMS, a hospital seeking to offer acute hospital care at-home services may not begin providing this service until it has also received approval from CDPH.

Medi-Cal will pay hospitals for acute inpatient care in both fee-for-service and managed care for Medi-Cal beneficiaries who receive care under this program. Managed care plans (MCPs) must authorize and reimburse hospitals providing inpatient acute care services at-home through the Acute Hospital Care at Home program at the same rate they would if the services were provided in a traditional hospital setting. DHCS will reimburse fee-for-service care as if the services were provided in a traditional hospital setting, following current payment authorization processes and reimbursement methodologies.

For Medi-Cal enrolled hospitals participating in the program, MCPs are responsible for knowing each participating hospital’s waiver authorities and for authorizing members to receive acute care inpatient services at home as medically appropriate. MCPs are responsible for tracking each hospital’s approved waiver. MCPs are responsible for ensuring that their subcontractors and network providers comply with all applicable state and federal laws and regulations, contract requirements, and other DHCS guidance, including APLs and policy letters. Each MCP must communicate these requirements to all subcontractors and network providers.

Currently, CMS has approved Adventist Health for Hospital at Home services in California for hospitals located in Bakersfield, Glendale, Ukiah and Simi Valley. Additionally, Adventist Health is awaiting federal approval for hospitals in Boyle Heights and Marysville. In addition, the University of California, Irvine Health is in the process of applying to CMS and CDPH for the program.

Providers are also encouraged to review All Facility Letter 20-90, published by the CDPH, for program flexibility requirements before providing acute Hospital Care at Home services. DHCS will publish additional information on the DHCS COVID-19 Response webpage and the All Plan Letters webpage in the future regarding program operations and approved providers of the Acute Hospital Care at Home services.

For additional COVID-19 information and resources, we encourage you to review the following resources:

2. Infectious Agent Antigen Detection by Immunoassay Tests are CLIA-Waived

The following tests are considered to be Clinical Laboratory Improvement Amendments (CLIA)-waived when performed with a CLIA-waived test kit:

CPT® Code Effective Date Description
87428 For dates of service on or after November 10, 2020 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B
87811 For dates of service on or after October 6, 2020 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

These codes may be billed with modifier QW to be recognized as a waived test.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path bil (11, 12)

3. Rates Are Updated for CPT COVID-19 Testing Codes 87636, 87637 and 87811

Effective for dates of service on or after October 6, 2020, the rates for CPT® codes 87636 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] and influenza virus types A and B, multiplex amplified probe technique), 87637 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)], influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique) and 87811 (infectious agent antigen detection by immunoassay with direct optical [ie, visual] observation; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)]) are updated.

Codes Description Medicare Rate
87636 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique $142.63
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique $142.63
87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respirator syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) $41.38

The codes above are exempt from the 10% payment reductions in Welfare and Institutions (W&I) Code section 14105.192, as described in Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

4. 2021 Quarter 1 HCPCS Updates Not Yet Adopted

The 2021 Quarter 1 updates to the Healthcare Common Procedure Coding System (HCPCS) Level II codes are effective for Medicare on January 1, 2021. However, due to a delay caused by the coronavirus disease 2019 (COVID-19), Medi-Cal is not able to adopt the updates in time to publish the associated policy in the January Medi-Cal Update.

Providers should not use the 2021 Quarter 1 HCPCS Level II codes to bill for Medi-Cal or Presumptive Eligibility for Pregnant Women (PE4PW) services until notified to do so in a future Medi-Cal Update.

5. Teprotumumab-trbw is a New Medi-Cal Benefit

Effective for dates of service on or after October 1, 2020, HCPCS code J3241 (Injection, teprotumumab-trbw, 10 mg) is a Medi-Cal benefit. An approved Treatment Authorization Request (TAR) is required for reimbursement.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (22); inject drug s-z (11,12)

6. Policy Updates for Selected Injection HCPCS Codes

Effective for dates of service on or after February 1, 2021, policy for HCPCS codes J0490 (injection, belimumab, 10 mg), J1335 (injection, ertapenem sodium, 500 mg) and J2182 (injection, mepolizumab, 1 mg) have been updated.

HCPCS code J0490 has been approved for treatment of Systemic Lupus Erythematosus (SLE) for children 5 years of age and older. HCPCS code J1335 is now a benefit. HCPCS code J2182 has been approved for children 6 to 11 years of age with severe eosinophilic asthma.

7. Updates to Billing Policy for Lanreotide

Effective for dates of service on or after February 1, 2021, policy has been updated for HCPCS code J1930 (injection, lanreotide, 1 mg). Code J1930 is for the treatment of patients 18 years of age and older. A Treatment Authorization Request (TAR) is no longer required for reimbursement.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (14); inject drug i-m (16, 17); modif used (13); non ph (14, 28)
Chronic Dialysis Clinics inject cd list (14); inject drug i-m (16, 17); modif used (13)
Pharmacy inject cd list (14); inject drug i-m (16, 17)

8. Billing Assistance Program Available to Medi-Cal Providers

The Small Provider Billing and Training Program is a free, full-service program offered to providers who submit fewer than 100 Medi-Cal claim lines per month and who are not conducting business with an outside billing service or agency. In this program, Claim Specialists and Regional Field Representatives work directly with providers during the 12-month structured program assisting providers with completing and submitting their Medi-Cal claims.

If you are interested in learning more about Medi-Cal billing and want for more information on how to enroll in the Small Provider Billing Assistance Unit (SPBU) and Training Program, call the SPBU at 1-916-636-1275 or contact the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, excluding holidays.

9. Updated Policy Effective Date for Billing Immune Globulins

The below article, originally published October 6, 2020, has been corrected to remove Xembify from the list of immune globulins billable with CPT code 90284.

Superseding communication from the Department of Health Care Services (DHCS) in the July 2020 General Bulletin, new changes are introduced for billing and claims submission of various HCPCS Level II and Current Procedural Terminology (CPT®) codes for Physician Administered Drugs (PAD).

As part of ongoing efforts to ensure consistency and accuracy in billing and provider reimbursements, providers must note the following when submitting claims for specific biologicals and drugs.

Preferred Codes for Billing Biologicals With Both CPT and HCPCS Codes:

The biologicals below are billed with both CPT and HCPCS codes. The HCPCS codes are often more specific than the CPT codes. Now effective for dates of service on or after October 1, 2019, for reimbursement, providers must submit claims for the listed CPT codes using the corresponding HCPCS codes as shown in the table below:

Procedure Codes Procedure Descriptions Code(s) to Bill with
90281 Immune globulin (Ig), human, for intramuscular use J1460 or J1560
90283 Immune globulin (IgIV), human, for intravenous use J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572 or J1599
90284 Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each Bill J1555 (Cuvitru) & J1559 (Hizentra)

Continue to bill 90284 for all other immune globulins used for subcutaneous infusions
90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use J0850
90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular J2790 or J2791
90385 Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use J2788
90386 Rho(D) immune globulin (RhIgIV), human, for intravenous use J2791 or J2792
90389 Tetanus immune globulin (TIg), human, for intramuscular use J1670

Providers may continue to bill for Gammagard liquid, Gammaked, Gammunex-C and Cutaquig with CPT code 90284.

Cuvitru must be billed with J1555 and Hizentra with J1559.

Processes for Rebilling and Payment Correction of Rho (D) Immune Globulins for Dates of Service On or After October 1, 2019 to August 31, 2020 for Providers Who Billed With CPT Codes and Were Denied or Underpaid:

For providers who previously billed with CPT codes 90384 and 90385 and claims were denied:

  • Rebill with the corresponding J codes as indicated in the table above.

    • It is not necessary to submit a Treatment Authorization Request (TAR).

    • This ensures that providers are reimbursed at the full Medi-Cal rate available.

      • If rebill is submitted beyond the 6-month billing limitation, timeliness of the rebill is waived.

For providers who billed with CPT codes 90384 and 90385 and were reimbursed only the injection administration fee of $4.46:

  1. Submit a Claims Inquiry Form (CIF) to void the claim billed with the CPT code.
    • There is no time restriction on this process.

    • When completing the CIF, providers must enter the information exactly as it appears on the Remittance Advice Details (RAD) to ensure the claim is located within the claims processing system.

  2. Rebill using the corresponding J code as indicated in the table above for appropriate reimbursement following the void of the CPT code.

    • These steps ensure that providers are paid at the full Medi-Cal rate available.

    • It is not necessary to submit a TAR.

      • If rebill is submitted beyond the 6-month billing limitation, timeliness of the rebill is waived.

Instructions regarding the submission of CIF can be found here in the Billing Basics Outreach & Education workbook.

Erroneous Payment Correction (EPC) for Dates of Service from August 1, 2020 to August 31, 2020

  • EPCs are processed for all claims billed with J-codes, which were inappropriately denied for dates of service from August 1, 2020, to August 31, 2020.

    • EPCs are processed automatically. No action is required on the part of providers.

10. Monthly Six Prescription Limit and Pharmacy Copay are Terminated

On May 13, 2020, in light of the coronavirus disease 2019 (COVID-19) pandemic and pursuant to federally approved State Plan Amendment 20-0024, the Department of Health Care Services (DHCS) temporarily suspended the monthly six prescription (6 Rx) per beneficiary limit outlined in Welfare and Institutions Code (W&I Code), Section 14133.22, until further notice. The 2020 Budget Health Omnibus Trailer Bill – AB 80/SB 102 made that change permanent along with the elimination of the one-dollar pharmacy copay. Therefore, effective January 1, 2021, the monthly 6 Rx per beneficiary limit and the one dollar pharmacy copay will be permanently eliminated.

11. 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 January 1, 2021
NDC Labeler Code Contracting Company's Name
71390 Acacia Pharma Ltd
71671 Agile Therapeutics, Inc.
72769 Biocryst Pharmaceuticals, Inc.
73292 NS Pharma, Inc.
73380 Innate Pharma, Inc.
73473 Solaris Pharma Corporation
73594 Pharmacosmos Therapeutics Inc.
79672 Nextgen Pharmaceuticals LLC
Terminations, effective January 1, 2021
NDC Labeler Code Contracting Company's Name
00327 Guardian Labs Div United-Guardian Inc.
11788 AiPing Pharmaceutical, Inc.
24090 Akrimax Pharmaceuticals LLC
42238 Vidara Therapeutics Inc.
52747 U.S. Pharmaceutical Corporation (USPCO)
53014 Celltech Pharmaceuticals
58281 Medtronic, Inc.
61364 Biocryst Pharmaceuticals, Inc.
61971 Vista Pharmaceuticals, 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 (3, 5–7, 10–23)

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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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