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Medi-Cal Update

Chronic Dialysis Clinics | June 2022 | Bulletin 573

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1. Update: Second Booster Dose for Select COVID-19 Boosters Now a Benefit

Effective for dates of service (DOS) on or after March 29, 2022, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine and Moderna COVID-19 vaccine, to allow for use of a second booster dose, to be administered at least four months after initial booster dose, to the following groups for each respective vaccine:

Pfizer-BioNTech:

  • Individuals 12 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.

  • Individuals 50 years of age and older.

Moderna:

  • Individuals 18 years of age or older with certain kinds of immunocompromise. This includes individuals who have undergone solid organ transplantation, or who are living with conditions that are considered to have an equivalent level of immunocompromise.

  • Individuals 50 years of age and older.

Providers may now submit claims for second booster dose administration using the following codes:

  • Pfizer:

    • Administration Code 0004A for the originally authorized formulation (phosphate buffered saline)

    • Administration Code 0054A is for the Tris buffered formulation

  • Moderna:

    • Administration Code 0064A

    • Administration Code 0094A for new booster formulation (50 mcg/0.5 ml)

Billing:

Providers can now bill for administration code 0094A. A booster dose of any manufacturer cannot be billed for the same recipient more than once on the same DOS.

For the most current information regarding Medi-Cal’s COVID-19 response, see the COVID-19 Medi-Cal Response page on the Medi-Cal Provider website.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (41, 42, 44, 45); immun cd (5)

2. Age Eligibility and Availability Revised for Cabenuva

Effective for dates of service on or after March 29, 2022, the minimum age for HCPCS code J0741 (injection, cabotegravir and rilpivirine, 2 mg/3 mg), Cabenuva, is reduced from 18 years of age to 12. Cabenuva contains the two long-acting HIV-1 antiretroviral drugs cabotegravir and rilpivirine.

In addition, the network of specialty pharmacies, specialty distributors and wholesalers for Cabenuva have been updated to reflect current offerings and contact information.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after March 29, 2022, 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.

Provider Manual(s) Page(s) Updated
Chronic Dialysis
Clinics and hospitals
General Medicine
Obstetrics
Rehabilitation
Pharmacy
inject drug a-d (42–45)

3. New Medi-Cal Benefit for Hepatitis B Vaccine

As previously announced in the News article titled “Hepatitis B Vaccine Code 90759 is Now a Medi-Cal Benefit,” effective for dates of service on or after January 1, 2022, CPT® code 90759 (hepatitis B vaccine [HepB], 3-antigen [S, Pre-S1, Pre-S2], 10 mcg dosage, 3 dose schedule, for intramuscular use) is a Medi-Cal benefit.

CPT code 90759 is reimbursable for recipients 18 years of age or older and modifiers SA, SB, U7, UD and 99 are allowable.

A Treatment Authorization Request (TAR) is not required for reimbursement.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics immun (12, 13); immun cd (2, 3); inject cd list (12); modif used (5)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (12, 13); immun cd (2, 3); inject cd list (12); modif used (5); non ph (14, 29)
Pharmacy immun (12, 13); immun cd (2, 3); inject cd list (12)

4. One Time Injection Administration Fee Update

As a reminder, for physician-administrated drugs (PAD) that are assigned a Conversion Indicator equal to 30, the price listed on the Medi-Cal Rates page of the Medi-Cal Providers website includes the one-time injection administration fee of $4.46. Since the injection administration fee is applied only once for each drug administered, subsequent units claimed will have the administration fee subtracted from the published rate.

Examples of the correct way to calculate this fee below:

Procedure Code Procedure Description Unit Value Basic Rate Conv Ind
J0696 Injection, ceftriaxone sodium, per 250 mg 4.96 $4.96 $4.96

Billed units: 2

  • Correct: ($4.96 x 1 unit) + ($4.96 - $4.46 admin fee) x 1 unit = $5.46

  • Incorrect: $4.96 x 2 units = $9.92
Procedure Code Procedure Description Unit Value Basic Rate Conv Ind
J0884 Injection, argatroban, 1 mg (for ESRD on dialysis) 7.50 $7.50 030

Billed units: 4

  • Correct: ($7.50 x 1 unit) + ($7.50 - $4.46 admin fee) x 3 units = $16.62

  • Incorrect: $7.50 x 4 units = $30.00

Providers can refer to the Medi-Cal Rates Conversion page, the Injections: An Overview section of the Medi-Cal providers manual or contact our Telephone Service Center (TSC) at 1-800-541-5555 to receive further assistance.

5. National Correct Coding Initiative Quarterly Update for July 2022

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 claims received on or after July 1, 2022.

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

6. July 2022 Medi-Cal Provider “Coffee Break” Event

Medi-Cal's Outreach and Education department, along with the Department of Health Care Services is offering a “Coffee Break” event in July for category specific topics.

Topics discussed will include the following:

Topic Date
Remittance Advice Details July 5 and July 19
Medi-Cal Resources July 5 and July 19
Claims Follow-up July 6 and July 20
Eligibility/Share of Cost (SOC) July 6 and July 20
Lab Services July 7 and July 21
Home Health/Early and Periodic Screening Diagnostic and Treatment (EPSDT) July 7 and July 21
Medical Transportation July 12 and July 26
Durable Medical Equipment and Medical Supplies (DME) July 12 and July 26
Inpatient Obstetrics (OB) July 13 and July 27
Family Planning, Access, Care and Treatment (Family PACT) July 13 and July 27
California Children's Services (CCS)/Genetically Handicapped Person's Program (GHPP) July 14 and July 28
Obstetrics (OB)/Comprehensive Perinatal Services Program (CPSP) July 14 and July 28

Providers may visit the Medi-Cal Learning Portal (MLP) to view available coffee break times and to register in the Event Calendar.

Providers are encouraged to bring questions relating to the “Coffee Break” session topic. This is an open forum, therefore, claim examples are not needed for this event.

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

7. August 2022 Medi-Cal Provider Training Webinars

Outreach and Education (O&E) along with the Department of Health Care Services (DHCS) are offering category specific webinar sessions in August.

Session Date
Medi-Cal Resources 101 August 2
Navigating the Medi-Cal Website and Online Billing August 2 and 9
Long Term Care August 4
Inpatient and Outpatient Services August 9
Claims Follow-Up August 11
Health Access Programs August 16, 18 and 23
Hospital Presumptive Eligibility August 16
Every Woman Counts August 23
Durable Medical Equipment & Medical Supplies August 25
Medical Transportation Service August 25
Home Health Services August 30

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 Providers website.

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

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9. Provider Manual Revisions



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