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Medi-Cal Update

Durable Medical Equipment and Medical Supplies | December 2020 | Bulletin 543

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1. 2021 CPT® Annual Update

The 2021 Quarter 1 updates to the Current Procedural Terminology (CPT) codes are available in the December 2020 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for the dates of service on or after January 1, 2021. Please refer to the 2021 CPT code book for complete code descriptions.

The 2021 Quarter 1 updates to the Healthcare Common Procedure Coding System (HCPCS) Level II codes are also 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.

Provider Manual(s) Page(s) Updated
AIDS Waiver Program modif app (10, 11)
Audiology and Hearing Aids audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11)
Chronic Dialysis Clinics cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12)
Clinics and Hospitals
General Medicine
cal child ser (1, 25, 34, 36, 37, 50, 56); cardio (3); eval (2, 4–7, 9, 13, 14, 27, 29); ev woman (24, 31, 32); fam planning (6, 9, 10, 12); hyst (3); immun (31); immun cd (1); medne neu (5); medne oto (1); medne pul (4); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9, 11, 25, 27); once (7); ophthal (2, 3, 12); path molec (9, 16, 17, 30, 43–47, 51, 52, 56, 60, 70, 93); preg determ (1); preg early (5); preg glo (4); preg per (2); preg post (6); presum bill (1, 2, 4, 9, 10, 11, 12, 16); prev (2, 3, 6, 8, 9); psych (4); radi (5); radi dia (3); radi onc (1); rates max (5); respir (4); spec (2); surg aud (5); surg bil mod (7, 8); surg cardio (3, 10); surg muscu (2); surg nerv (1); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Community Based Services audio (4)
Durable Medical Equipment cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); respir (4)
Home Health Agencies/Home and Community-Based Services cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); preg post (6)
Inpatient Services cal child ser (1, 25, 34, 36, 37, 50, 56); hyst (3); preg post (6); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Local Education Agency
Medical Transportation
Orthotics and Prosthetics
cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11)
Obstetrics cal child ser (1, 25, 34, 36, 37, 50, 56); eval (2, 4–6, 8, 12, 13, 26, 28); ev woman (24, 31, 32); fam planning (6, 9, 10, 12); hyst (3); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9, 11, 25, 27); once (7); path molec (9, 16, 17, 30, 43–47, 51, 52, 56, 60, 70, 93); preg determ (1); preg early (5); preg glo (4); preg per (2); preg post (6); presum bill (1, 2, 4, 9, 10, 11, 12, 16); radi (5); radi dia (3); radi onc (1); rates max (5); surg bil mod (7, 8); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Pharmacy cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); pharm serv (2–7, 10); presum bill (1, 2, 4, 9, 10, 11, 12, 16)
Psychological Services cal child ser (1, 25, 34, 36, 37, 50, 56); psychol (6); psychol cd (1); spec (2)
Rehabilitation Clinics audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9,11, 25, 27); respir (4)
Therapies audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); respir (4)
Vision Care cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); pro serv (3, 9, 11, 12, 19); rates max optom (2–4)

2. Medi-Cal Lengthens Transition Time to Full Implementation – Go-Live on April 1, 2021

Given the ongoing challenges and constantly evolving health care landscape associated with the unprecedented coronavirus disease 2019 (COVID-19) public health emergency (PHE), the Department of Health Care Services (DHCS), in partnership and collaboration with Magellan Medicaid Administration, Inc. (Magellan), has decided to lengthen the time for the full implementation of the transition to Medi-Cal Rx by three  months. DHCS and Magellan will continue to dedicate their combined efforts and rigorous preparations towards Assumption of Operations (AOO) for Medi-Cal Rx on April 1, 2021. In the interim, all current processes and protocols, both effectuated by DHCS and our Medi-Cal managed care plans (MCPs), respectively, will remain unchanged and in place until Medi-Cal Rx launches.

While neither DHCS nor Magellan takes this decision lightly, we are confident that given the COVID-19 PHE, this decision is in the best interests of our Medi-Cal beneficiaries and providers. Lengthening the time for full implementation will help to ensure a more complete transition, as well as mitigate impacts to beneficiaries in accessing their medication. Moving the launch of Medi-Cal Rx to April 1, 2021, will provide additional and valuable opportunities for Medi-Cal providers, beneficiaries, MCPs, and other interested parties to become better acclimated to, and familiar with new Medi-Cal Rx policies and processes, through additional messaging from DHCS and Magellan, additional targeted stakeholder engagement and outreach efforts and additional provider trainings.

Please note that DHCS will be working to update applicable provider guidance and associated Medi-Cal Rx provider bulletins/Newsflash articles in the coming weeks to reflect the April 1, 2021, go-live date. With the exception of the three-month shift in the go-live date, all other aspects of the transition communicated to our providers via bulletins through the Medi-Cal and Medi-Cal Rx websites remain unchanged.

DHCS appreciates your continued support and collaboration relative to this important project and looks forward to the successful launch and AOO of Medi-Cal Rx on April 1, 2021. If you have any questions about this notification, please feel free to direct them to the Medi-Cal Rx Project Team at RxCarveOut@dhcs.ca.gov.

3. Updates to the List of Enteral Nutrition Products

Effective for claims with dates of service on and after January 1, 2021, the List of Enteral Nutrition Products eligible for reimbursement through the Medi-Cal fee-for-service pharmacy delivery system is updated. The new spreadsheet, List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021, have newly added products, deleted products (on the Deletion Tab), and updated maximum acquisition cost (MAC) and estimated acquisition cost (EAC) for certain products.

The manufacturers guarantee providers can purchase the listed products at or below the MAC, upon request, for dispensing to Medi-Cal fee-for-service outpatient recipients.

Effective for dates of service on or after April 1, 2021, products on the spreadsheet, List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021, Deletion Tab will no longer be reimbursable, even with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). The MAC for these products is no longer guaranteed.

Note: Listing of a product is not a guarantee of its availability. The National Drug Code (NDC)-like product number approved on an authorization must be the same NDC-like product number dispensed to the recipient and claimed for reimbursement by the provider.

Recipients affected by these changes, should seek new prescriptions from their physician and new authorizations from their pharmacy provider for a comparable product on the List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021. Continuing care does not apply.

Medi-Cal recipients denied enteral nutrition products who believe the denial was in error, may ask for a state hearing by contacting the California Department of Social Services at 1-800-743-8525 or 1-855-795-0634, or by sending a written request to:


California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (1, 2, 15)

4. Pen Needles Policy Changed

Effective for dates of service on or after January 1, 2021, pen needles are billable by fee-for-service pharmacy providers on a pharmacy claim using the product’s 11-digit National Drug Code (NDC).

Pen needles reimbursable through the Medi-Cal fee-for-service delivery system, with or without prior authorization, are subject to the products on the List of Contracted Pen Needles. The 11-digit product NDC on the package (box) dispensed must be an exact match to the NDC billing code on the product list and the NDC submitted on the claim.

Providers are reminded of the upper billing limit (California Code of Regulations, Title 22, Section 51008.1) when billing for pen needles. The claim amount billed for pen needles should not exceed the amount that is the lesser of the following:

  • The usual charges made to the general public;

  • The net purchase price of the item (including all discounts and rebates), which shall be documented in the provider’s books and records, plus no more than 100 percent markup. Documentation shall include, but not be limited to, evidence of purchase such as invoices or receipts; or

  • The maximum allowable product cost (MAPC) of the item published on the List spreadsheet plus 23 percent dealer markup.

The maximum amount reimbursed to providers is the lesser of the following:

  • The amount billed, or

  • The MAPC plus 23 percent dealer markup.

The manufacturers have guaranteed, upon request, that Medi-Cal fee-for-service pharmacy providers can purchase the products listed in the List of Contracted Pen Needles at or below the maximum acquisition cost (MAC) for administering through the Medi-Cal fee-for-service delivery system. A prior authorization is required for pen needles when the quantity needed exceeds the 100 per 30-day period limitation.

The Medical Supplies Billing Codes, Units and Quantity Limits List was also updated.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1, 7–15)

5. Rate Correction for Oxygen Systems

The Durable Medical Equipment (DME): Oxygen and Respiratory Equipment provider manual section incorrectly stated the rate for renting the following oxygen systems as $144.74. The rate has been corrected to $107.77, effective retroactively for dates of services on or after January 1, 2019. Additionally, the rate for the following codes billed with modifier QA or QE is adjusted from $72.37 to $53.88 and the rate when billed with modifier QB, QF, QG or QR is adjusted from $217.11 to $161.65.

No action is required by providers. Claims will be automatically adjusted, as appropriate, through an Erroneous Payment Correction.

HCPCS Code Definition
E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura oxy (39)

6. Updated Policy for Ventricular Assist Devices

Effective retroactively for various dates of service, HCPCS codes Q0477 through Q0504 and Q0506 through Q0509 have been updated to be surgical supplies or devices and are no longer designated as Durable Medical Equipment (DME), orthotics or prosthetics.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids tax (8)
Clinics and Hospitals
General Medicine
modif used (14); surg cardio (10)
Dialysis modif used (14)
Durable Medical Equipment dura cd (62); dura cd fre (11); dura other (35); tax (8)
Obstetrics modif used (14)
Orthotics and Prosthetics dura cd (62); dura cd fre (11); tax (8)
Pharmacy dura cd (62); dura cd fre (11); dura other (35); tax (8)
Rehabilitation Clinics modif used (14)
Therapies dura cd (62); dura cd fre (11)

7. National Correct Coding Initiative Quarterly Update for January 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 January 1, 2021.

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

8. January Through February 2021 Medi-Cal Provider Training Webinars

Beginning January 5, 2021 and continuing throughout the month of February, Medi-Cal providers may participate in provider training webinars that are:

  • Held twice a day on Tuesdays and Thursdays at 10:00 a.m. and 2:00 p.m.

  • Hosted in real-time by a Medi-Cal Regional Representative

  • Designed to cover basic, advanced and specialty billing topics

Registration for the training webinars is available on the Medi-Cal Learning Portal (MLP) or the Medi-Cal home page.

Providers will be able to print class materials and ask questions during the live webinar training sessions. The MLP offers training courses that can be viewed according to your schedule if you are unable to attend one of the live webinars.

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

9. Updates to List of Contracted Tracheostomy Supplies

Effective for dates of service on or after December 1, 2020, the List of Contracted Tracheostomy Supplies is updated. Several products that meet the description of contracted HCPCS billing codes A7520 (Tracheostomy/laryngectomy tube, noncuffed, polyvinyl chloride (PVC), silicone or equal, each) and A7521 (Tracheostomy/laryngectomy tube, cuffed, polyvinyl chloride (PVC), silicone or equal, each) have been added.

10. Get the Latest Medi-Cal News: Subscribe to MCSS Today

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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.

11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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