Family PACT Update

April 2022 | Bulletin 175


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1. Coming Soon: Second Booster Dose for Select COVID-19 Vaccines

Effective for dates of service 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.

Additionally, the FDA authorized a booster dose formulation (50 mcg/0.5 ml) of the Moderna COVID-19 booster vaccine. Providers administering a booster dose (regardless of administration sequence) using this new formulation will be required to submit a new CPT® administration code when billing Medi-Cal: CPT code 0094A.

Next Steps

The Department of Health Care Services (DHCS) is aggressively pursuing the necessary system and operational changes required to enable successful claims adjudication for administration of a second booster dose of either the Pfizer-BioNTech vaccine or Moderna vaccine. Systems updates are also required to allow Medi-Cal to accept claims for CPT code 0094A.

Medi-Cal will announce when the claims adjudication system is prepared to appropriately adjudicate submitted claims. Until then, providers are advised to administer the booster dose to the eligible populations and hold the claim submission until further notice.

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.

2. Child Health and Disability Prevention Program and Expanding Children's Presumptive Eligibility

On February 25, 2022, the Department of Health Care Services (DHCS) published a new Child Health and Disability Prevention (CHDP) Program Letter 22-02 and CHDP Provider Notice 22-02 notifying CHDP programs and CHDP providers statewide of the DHCS Proposal to Discontinue the CHDP Program by July 1, 2023 in order to simplify and streamline the delivery of services to children and youth under the age of 21, in alignment with the goals of the California Advancing and Innovating Medi-Cal (CalAIM) initiative.

For more information providers can visit the CHDP Program Letters and Provider Information Notices website, or review the letter and notice in the links below:

Further announcements regarding this transition will be released as they become available in the coming months.

Providers can visit the DHCS CHDP Program website for CHDP program related information.

3. Updates to Family PACT Laboratory Services Policy

Effective for dates of service on or after May 1, 2022, the Family Planning, Access, Care and Treatment (Family PACT) program laboratory services policy for Sexually Transmitted Infections is updated to align with the Centers for Disease Control and Prevention, Sexually Transmitted Infections Treatment Guidelines, 2021, as follows:

  • CPT® code 87563 (infectious agent detection by nucleic acid [DNA or RNA]; Mycoplasma genitalium, amplified probe technique) is added as a benefit for use as a diagnostic test for recurrent urethritis, cervicitis, and in some cases of pelvic inflammatory disease.

  • ICD-10-CM code N34.1 is covered for males with CPT codes 81000, 81001, 81002, 81003, 81005, 81015, 87205, 87210, 87491, 87591 and HCPCS code Q0111.

4. Updates to Family PACT Policy for E&M and E&C Office Visits Billed on the Same DOS

Effective January 1, 2021, the Family Planning Access, Care and Treatment (Family PACT) Program updated its policy to allow Education and Management (E&M) and Education and Counseling (E&C) office visits to be billed on the same date of service (DOS) in limited circumstances. Post-implementation, the Department of Health Services (DHCS) was made aware that the policy conflicted with the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits.

Effective for DOS on or after March 28, 2022, DHCS will allow a PTP edit to bypass the NCCI audit if an appropriate modifier is appended to the E&M code but will not require medical record documentation for Family PACT claims.

Therefore, the Family PACT Program is updating its policy to reflect the following:

  • Family PACT providers are required to add modifier 25 (significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E&M code when billed with an E&C visit on the same DOS.

  • Medical record documentation is not required to be submitted with the claim.

In a forthcoming announcement, the Family PACT Program will notify providers how claims denied between January 1, 2021 and March 27, 2022, will be adjudicated and provide additional instructions.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Durable Medical Equipment
Medical Transportation
Orthotics and Prosthetics
Therapies
General Medicine
Obstetrics
AIDS Waiver Program
Clinics and Hospitals
Chronic Dialysis Clinics
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Rehabilitation Clinics
Vision Care
modif app (2)
Family PACT office (8–10)

5. Vaccine Counseling Services are Reimbursable using E&M Office or Other Outpatient Visit CPT codes

California recognizes the importance of vaccinating all Medi-Cal beneficiaries against infectious diseases, including COVID-19. Vaccine counseling can reduce vaccine hesitancy by allowing beneficiaries to consult with and receive vaccine information directly from their regular physician or medical practitioner. Medi-Cal reimburses vaccine counseling services when a beneficiary does not receive the vaccine from the same provider on the same date of service. Physicians or Outpatient providers may report vaccine counseling-only services to Medi-Cal by using the most appropriate Evaluation and Management (E&M) Office or other Outpatient visit CPT® code, along with one of the following ICD-10-CM diagnosis codes: Z28 – Z28.9 or Z71.85.

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