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Medi-Cal Update

Durable Medical Equipment and Medical Supplies | August 2021 | Bulletin 551

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1. New DME Rental Benefit: Phototherapy Light for Infants

Effective for dates of service on or after September 1, 2021, HCPCS code E0202 (phototherapy [bilirubin] light with photometer) is a Medi-Cal benefit for infants as a daily rental only. Because the light is rented, modifier RR is required. For reimbursement, documentation must indicate that the recipient meets the following criteria:

  • The infant’s total serum bilirubin is in the “optional range” as defined by the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia; and

  • The infant is feeding, voiding and stooling well and appears well; and

  • Close follow-up evaluation can be accomplished

Claims submitted to bill for the phototherapy light may be submitted under the mother’s Medi-Cal ID if the infant’s Medi-Cal eligibility has not yet been established. Claims that use the mother’s Medi-Cal ID for the infant, must indicate in the Patient Relationship to Insured field (Box 6) that the “patient is the child of the insured.”

The frequency limit for HCPCS code E0202 is 10 days per lifetime, per infant. A Treatment Authorization Request (TAR) can override the frequency limit when more than one infant born to the same mother (for example, twins, or infant from subsequent birth) requires phototherapy. When phototherapy is needed for more than one infant, claims for phototherapy require a statement in the Additional Claim Information field (Box 19) specifying the number of infants needing phototherapy at this time or that a previous claim was submitted for a sibling who also required phototherapy.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura cd (9); dura cd fre (2); dura other (2, 15, 16)
Orthotics and Prosthetics
Therapies
dura cd (9); dura cd fre (2)

2. Correction to HCPCS Codes E1065 and E0165

Effective retroactively for dates of service on or after December 31, 2003, the Centers of Medicare and Medicaid Services (CMS) terminated code E1065 (power attachment to convert any wheelchair to motorized wheelchair, e.g., solo). Code E0165 (commode chair, mobile or stationary, with detachable arms) was terminated instead of E1065 and later reactivated. The Medi-Cal Provider Manual has been updated accordingly to reflect termination of E1065.

Providers who submitted claims under E0165 were erroneously denied with Remittance Advice Details (RAD) code 0037 (Health Care Plan/Mental Health Care enrollee, capitated service not billable to Medi-Cal). As the required system changes have since been implemented, an Erroneous Payment Correction (EPC) will be installed to reprocess any impacted claims for E0165.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Orthotics and
Pharmacy
Therapies
dura cd (6, 52); dura cd fre (6); medi non hcp (2)
AIDS Waiver Program
Audiology and Hearing Aids
Clinics and Hospitals
General Medicine
Heroin Detoxification
Home Health Agencies/
Home and Community-Based Services
Hospice Care Program
Medical Transportation
Obstetrics
Psychological Services
Rehabilitation Clinics
Vision Care
medi non hcp (2)

3. Updates to the List of Medical Supplies Billing Codes, Units and Quantity Limits

Effective for dates of service on or after November 1, 2021, HCPCS code A4459 (manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type) is added as a medical supply billing code, requiring a Treatment Authorization Request (TAR), on the List of Medical Supplies Billing Codes, Units and Quantity Limits.

In addition to TAR approval, claims submitted using HCPCS code A4459 require documentation of product cost (an invoice, manufacturer’s catalog page or price list) attached to the claim for reimbursement.

Effective for dates of service on or after January 1, 2022, claims with approved TARs using HCPCS code T5999 (supply, not otherwise classified) for reimbursement of a manual pump-operated enema system and its accessories will be denied.

Correction Made to Quantity Limits for Wound Care HCPCS Code A6245

The List of Medical Supplies Billing Codes, Units and Quantity Limits is updated with the correct quantity limits for wound care supply HCPCS code A6245, (hydrogel dressing, wound cover, sterile, pad size 16 sq in or less, with any size adhesive border, each dressing). The correct quantity limit without authorization for HCPCS code A6245 is 12 dressings per wound per 27-day period.

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