Medi-Cal Update

General Medicine | February 2016 | Bulletin 500

Print Medi-Cal Update
 

1. Mailing Address Update for Paper TAR Submissions

Effective immediately, unless otherwise directed by Medi-Cal, all paper Treatment Authorization Requests (TARs) should be sent to the following location:

TAR Processing Center
820 Stillwater Road
West Sacramento, CA 95605-1630

If a provider submits a TAR to a field office, the TAR will be returned to the provider with instructions to send the TAR to the TAR Processing Center.

For TAR status or issues, providers may call the Telephone Service Center (TSC) at 1-800-541-5555. Providers outside of California may call (916) 636-1980.

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2. AB 97 Dental Services Exemptions

Effective for dates of service on or after July 1, 2015, the following dental services and ancillary services are exempt from the Assembly Bill (AB) 97 10 percent provider payment reduction:

An Erroneous Payment Correction (EPC) will be issued to resolve improperly reimbursed claims.
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3. Filgrastim-sndz Added as a New Drug Benefit

Effective retroactively for dates of service on or after March 6, 2015, HCPCS code Q5101 (injection, filgrastim [G-CSF], biosimilar, 1 mcg) is a new Medi-Cal benefit.

Filgrastim-sndz is only reimbursable when billed with one of the following ICD-10-CM diagnosis codes:

C92.00 – C92.02 D46.4 D46.Z Z51.11
D46.0 D46.9 D70.1 Z52.001
D46.1 D46.A D70.4 Z52.011
D46.20 D46.B D70.8 Z94.84

When billing for more than 1,200 mcg, providers must document on the claim or on an attachment that the patient weighs more than 100 kg.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
inject cd list (8); inject drug e-h (20)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (8); inject drug e-h (20); non ph (11, 22)
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4. Correction: ICD-10-CM Diagnosis Codes Restored to Two HCPCS Codes

A page of the Non-Injectable Drugs section of the provider manual inadvertently reverted from ICD-10-CM diagnosis code references to ICD-9-CM codes. This has been corrected. The two affected HCPCS codes are as follows:

HCPCS Code Description ICD-10-CM
S0189 Testosterone pellet, 75 mg E29.1, E29.8 or E29.9
J7336 Capsaicin 8% patch, per square centimeter B02.21 – B02.23, B02.7, B02.8

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non inject (8)
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5. Reimbursement of Erroneous Denials for Pregnancy-Related Office Visit

A claims processing issue has been identified that can cause claims to erroneously deny when billed with HCPCS code Z1032 (initial comprehensive pregnancy-related office visit) and one of the following ICD-10-CM diagnosis codes:

ICD-10-CM Description
O30.021 Conjoined twin pregnancy, first trimester
O30.022 Conjoined twin pregnancy, second trimester
O30.023 Conjoined twin pregnancy, third trimester
O30.029 Conjoined twin pregnancy, unspecified trimester
O36.8210 Fetal anemia and thrombocytopenia, first trimester, unspecified
O36.8211 Fetal anemia and thrombocytopenia, first trimester, fetus 1
O36.8212 Fetal anemia and thrombocytopenia, first trimester, fetus 2
O36.8213 Fetal anemia and thrombocytopenia, first trimester, fetus 3
O36.8214 Fetal anemia and thrombocytopenia, first trimester, fetus 4
O36.8215 Fetal anemia and thrombocytopenia, first trimester, fetus 5
O36.8219 Fetal anemia and thrombocytopenia, first trimester, other
O36.8220 Fetal anemia and thrombocytopenia, second trimester, unspecified
O36.8221 Fetal anemia and thrombocytopenia, second trimester, fetus 1
O36.8222 Fetal anemia and thrombocytopenia, second trimester, fetus 2
O36.8223 Fetal anemia and thrombocytopenia, second trimester, fetus 3
O36.8224 Fetal anemia and thrombocytopenia, second trimester, fetus 4
O36.8225 Fetal anemia and thrombocytopenia, second trimester, fetus 5
O36.8229 Fetal anemia and thrombocytopenia, second trimester, other
O36.8230 Fetal anemia and thrombocytopenia, third trimester, unspecified
O36.8231 Fetal anemia and thrombocytopenia, third trimester, fetus 1
O36.8232 Fetal anemia and thrombocytopenia, third trimester, fetus 2
O36.8233 Fetal anemia and thrombocytopenia, third trimester, fetus 3
O36.8234 Fetal anemia and thrombocytopenia, third trimester, fetus 4
O36.8235 Fetal anemia and thrombocytopenia, third trimester, fetus 5
O36.8239 Fetal anemia and thrombocytopenia, third trimester, other
O36.8290 Fetal anemia and thrombocytopenia, unspecified trimester, unspecified
O36.8291 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 1
O36.8292 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 2
O36.8293 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 3
O36.8294 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 4
O36.8295 Fetal anemia and thrombocytopenia, unspecified trimester, fetus 5
O36.8299 Fetal anemia and thrombocytopenia, unspecified trimester, other fetus

Providers should continue to submit claims timely. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.

ICD-10-CM codes O28.0 – O28.9 in conjunction with HCPCS code Z1032 will be removed from the provider manual with an effective date of October 1, 2015.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg early (3)
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6. Pregnancy-Related Claims May Erroneously Deny with ICD-10 Diagnosis Codes

The Department of Health Care Services (DHCS) has identified a claims processing issue that may cause claims to erroneously deny when billed with CPT-4 code 59025 (fetal non-stress test) or HCPCS code Z1030 (non-oxytocin fetal stress test) and certain ICD-10 diagnosis codes.

The Pregnancy: Early Care and Diagnostic Services section of the Part 2 provider manual listed the incorrect ICD-10-CM code range of O09.00 – O9A.53 for billing with CPT-4 code 59025 or HCPCS code Z1030. The following corrected ICD-10 diagnosis code ranges are allowable diagnoses for billing CPT-4 code 59025 or HCPCS code Z1030, effective for claims with dates of service on or after October 1, 2015.

O00.0 – O16.9 O77.0 – O77.9 O98.611 – O98.619
O21.0 – O21.9 O88.011 – O88.019 O98.711 – O98.719
O23.00 – O26.62 O88.211 – O88.219 O98.811 – O98.819
O26.821 – O26.849 O88.311 – O88.319 O99.011 – O99.119
O26.872 – O26.899 O90.5 – O90.81 O99.280 – O99.333
O28.0 – O31.8X0 O98.0 – O98.019 O99.340 – O99.353
O32.0XX0 – O41.1499 O98.111 – O98.119 O99.411 – O99.419
O42.00 – O43.119 O98.211 – O98.219 O99.511 – O99.830
O43.191 – O43.210 O98.311 – O98.319 O99.840 – O99.843
O43.810 – O60.03 O98.411 – O98.419 O9A.111 – O9A.53
O67.0 – O68 O98.511 – O98.519  

In addition, effective for dates of service on or after October 1, 2015, CPT-4 code 59025 is not reimbursable with ICD-10 diagnosis code O76 (abnormality in fetal heart rate and rhythm complicating labor and delivery) for a billing frequency greater than 10 times in 9 months.

DHCS will alert providers when the issue is resolved. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg early (17, 18)
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7. Erroneous Payment of CPT-4 Codes Billed with Pregnancy-Related ICD-10 Codes

The Department of Health Care Services (DHCS) has identified a claims processing issue that may cause claims billed with pregnancy-related ICD-10-CM codes A34, O00.0 – O9A.53, Z33.1 – Z36, or Z64.0 – Z64.1 to erroneously reimburse when billed with one of the following CPT-4 codes:

CPT-4 Code Description
76830 Ultrasound, transvaginal
76856 Ultrasound, pelvic, real time with image documentation; complete
76857      limited or follow-up
93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
93976      limited study

CPT-4 codes 76830, 76856 and 76857 (non-obstetric sonography procedures), and codes 93975 and 93976 (duplex scan of arterial/venous flow) are not reimbursable if billed in conjunction with ICD-10-CM codes A34, O00.0 – O9A.53, Z33.1 – Z36, or Z64.0 – Z64.1.

This issue affects claims for dates of service on or after October 1, 2015. DHCS will notify providers when the issue is resolved. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers should continue to submit claims in a timely manner. Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg early (15, 16)
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8. ICD-10-CM Correction for Fetal Monitoring

Effective October 1, 2015, CPT-4 codes 59050 (fetal monitoring during labor by consulting physician [i.e., non-attending physician] with written report; supervision and interpretation) and 59051 (…interpretation only) are not reimbursable with ICD-10-CM diagnosis codes O09.213 – O09.93.

Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
preg fetal (1)
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9. Updated Billing Policy for Antepartum Fetal Testing

Effective for dates of service on or after March 1, 2016, local code Z1030 (non-oxytocin fetal stress test) will be terminated. Code Z1030 will be crosswalked to CPT-4 code 59025 (fetal non-stress test).

When billing CPT-4 code 59025 more than 10 times in nine months, 59025 may now be billed in conjunction with ICD-10-CM diagnosis codes O36.8920 – O36.8999 (maternal care for other specified fetal problems).

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Acupuncture
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Medical Transportation
Orthotics and Prosthetics
Psychological Services Therapies
cms spec (7)
Adult Day Health Care Centers
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agency/Home and Community-Based Services
Hospice Care Program
Local Education Agency
Multiple Senior Services Program
ub spec op (6)
AIDS Waiver Program
Chronic Dialysis Clinics
Rehabilitation Clincs
modif (3); ub spec op (6)
Clinics and Hospitals altern (3); modif (3); preg early (17, 18); preg ex ub (8); presum (28); rates max (4); ub spec op (6)
General Medicine
Obstetrics
altern (3); cms spec (7); modif (3); preg early (17, 18); presum (28); rates max (4)
Pharmacy cms spec (7); presum (28)
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10. Update to Screening Mammography Reimbursement Restrictions

Effective for dates of service on or after March 1, 2016, in accordance with United States Preventive Services Task Force guidelines, reimbursement for screening mammograms is restricted to females 50 through 74 years of age with a frequency limit of one screening every two years when billed with the following codes:

HCPCS Code Description
G0202 Screening mammography, producing direct digital image, bilateral, all views
CPT-4 Code Description
77052 Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; screening mammography
77057 Screening mammography, bilateral (two-view film study of each breast)
77063 Screening digital breast tomosynthesis, bilateral

There are no diagnostic restrictions for screening mammograms. A Treatment Authorization Request (TAR) may override age restrictions. A TAR will override gender restrictions.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi dia (22, 24)
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11. Updated Policy for Biochemical Assays with Algorithmic Analyses

Effective for dates of service on or after March 1, 2016, CPT-4 codes 81500 (oncology [ovarian], biochemical assays of two proteins [CA-125 and HE4], utilizing serum, with menopausal status, algorithm reported as a risk score) and 81503 (oncology [ovarian], biochemical assays of five proteins [CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-albumin], utilizing serum, algorithm reported as a risk score) are reimbursable for females who meet the following criteria:

Codes 81500 and 81503 are reimbursable only when billed in conjunction with ICD-10-CM diagnosis code R19.09.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (30)
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12. EWC Provider Covered Procedures Forms Updated

The following Every Woman Counts (EWC) forms have been added to the Every Woman Counts (EWC) Manuals, Forms and Worksheets Web page and Forms Web page of the Medi-Cal website:

These forms have been updated to include EWC program benefits announced in the September 2015 Medi-Cal Update bulletins.

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13. ICD-10-CM Diagnosis Code Correction for Schizophrenia

ICD-10-CM diagnosis code F20.00 has been corrected to F20.0 (paranoid schizophrenia, paraphrenic schizophrenia) for aripiprazole in the Injections: Drugs A-D Policy section of the provider manual.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject drug a-d (5, 6)
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14. ICD-10-CM Diagnosis Codes Erroneously Denied for Minor Consent Program Claims

The Department of Health Care Services (DHCS) identified a claims processing issue causing Minor Consent Program claims for the following ICD-10-CM diagnosis codes to erroneously deny:

ICD-10-CM
Code
Description
Z30.014 Encounter for initial prescription of intrauterine contraceptive device
Z30.432 Encounter for removal of intrauterine contraceptive device
Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device
Z97.5 Presence of (intrauterine) contraceptive device

DHCS has corrected this issue. Providers should continue to submit claims in a timely manner. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates.

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15. ECMO/ECLS Services Code Conversion and Policy Updates

Effective retroactively for dates of service on or after January 1, 2015, multiple ECMO/ECLS services are added as Medi-Cal benefits. ECMO (Extracorporeal Membrane Oxygenation) is defined as the use of a modified cardiopulmonary bypass circuit for temporary life support for patients with potentially reversible cardiac and/or respiratory failure, also known as Extra Corporeal Life Support (ECLS). ECMO/ECLS provides a mechanism for gas exchange and cardiac support allowing for recovery from existing lung and/or cardiac disease. ECMO/ECLS is an accepted treatment modality for newborns with respiratory and/or cardiac failure unresponsive to conventional medical therapy.

Indications and Selection Criteria
ECMO/ECLS is indicated for but not limited to the following diagnoses:

Selection criteria include all of the following:

TAR/SAR Requirement
An approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) is required for reimbursement of CPT-4 codes 33946 and 33947 only. All other ECMO/ECLS services do not require an approved TAR or SAR.

Physician Services
Neonatology services directly related to the cannulation, initiation, management and discontinuation of the ECMO/ECLS circuit and parameters are distinct from the daily overall management of the patient.

Daily overall management of the patient may be separately reported using the relevant hospital inpatient services, or critical care evaluation and management CPT-4 codes, and may be reimbursed to any provider, same recipient and same date of service. Reference the 2015 Current Procedural Terminology – 4th Edition code book for detailed physician billing instructions for the ECMO/ECLS services for each code.

Inpatient Services
ECMO/ECLS must be performed in a neonatal intensive care unit approved by the California Children’s Services as both a Regional Neonatal Intensive Care Unit (NICU) and an ECMO center.

Code Conversion
The CPT-4 codes listed in the table below replace local HCPCS code Z0312 (ECMO of a single infant performed in an ECMO inpatient unit requiring the continuous personal care and monitoring by an ECMO physician/specialist over a 24-hour period) and represent ECMO/ECLS services. Assistant surgeon services are not payable for these CPT-4 codes

CPT-4 Code Description
33946* Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; initiation, veno-venous
33947* initation, veno-arterial
33948* daily management, each day, veno-venous
33949* daily management, each day, veno-arterial
33951 insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33953 insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age
33955 insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33957 reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33959 reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33963 reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)
33965 removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age
33969 removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age
33985 removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age
33987 Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial perfusion for ECMO/ECLS
33988 Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS
33989 Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

*CPT-4 codes 33946 – 33949 are not reimbursable when billed with modifier 63.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (19); medne (4–6); modif used (10); tar and non cd 3 (5, 6)
Inpatient Services medne (4–6); tar and non cd 3 (5–9)
Obstetrics eval (19); modif used (10); tar and non cd 3 (5, 6)
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16. Policy Change for HCPCS Code J7327

Effective for dates of service on or after October 1, 2015, HCPCS code J7327 (hyaluronan or derivative, monovisc, for intra-articular injection, per dose) should be billed as a medical device, not as a Physician Administered Drug (PAD). Recent claims for code J7327 for dates of service on or after October 1, 2015 will be reprocessed.

For an updated list of rates, visit the Medi-Cal Rates page on the Medi-Cal website.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (25)
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17. Updated List of Drugs Requiring a SAR for CCS and GHPP

Effective retroactively for dates of service on or after July 1, 2015, Ombitasvir/Paritaprevir/Ritonavir is added to the list of drugs requiring a Service Authorization Request (SAR) for the California Children's Services (CCS) program and the Genetically Handicapped Persons Program (GHPP).

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (7); genetic (9)
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18. Modifier Update for Intraoperative Neurophysiology Monitoring Codes

Effective retroactively for dates of service on or after September 1, 2013, CPT-4 code 95940 (continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes) and 95941 (continuous intraoperative neurophysiology monitoring, from outside the operating room or for monitoring of more than one case while in the operating room, per hour) are not reimbursable when billed with modifiers 26 (professional component) and TC (technical component). These codes are not split billable.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
modif used (10)
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19. Updated Rates for Advance Care Planning Consultations

Effective retroactively for dates of service on or after November 1, 2015, the rates have been updated for CPT-4 codes 99497 (advance care planning including the explanation and discussion of advance directives, such as standard forms, by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member[s], and/or surrogate) and 99498 (…each additional 30 minutes).

An Erroneous Payment Correction (EPC) will be issued for claims with dates of service on or after November 1, 2015.

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20. Aflibercept Indicated for Treatment of Diabetic Retinopathy in DME Patients

Effective for dates of service on or after March 1, 2016, HCPCS code J0178 (injection, aflibercept, 1 mg) is indicated for diabetic retinopathy in patients with diabetic macular edema (DME).

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
ophthal (7, 8)
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21. Indications for Nivolumab Updated

Effective for dates of service on or after March 1, 2016, the indications have been updated, including deletion of the term “squamous,” for HCPCS code C9453 (injection, nivolumab, 1 mg).

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
chemo drug e-o (14)
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22. Alert: California Upgrades Prescription Drug Monitoring Program to CURES 2.0

A new DUR Educational Article titled “Alert: California Upgrades Prescription Drug Monitoring Program to CURES 2.0” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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23. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 - Prescription Drugs and Drugs: Contract Drugs List Part 4 - Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date
Drug Summary of Changes Page(s) Updated
November 19, 2015 DARATUMUMAB Drug added, strength added, administration added, restriction added drugs cdl p1a (51)
February 1, 2016

HEPATITIS A VIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (32)
February 1, 2016 HEPATITIS A & B VIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (32)
February 1, 2016 HEPATITIS B VIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (32)
February 1, 2016 HUMAN PAPILLOMAVIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (33)
February 1, 2016 MEASLES, MUMPS, AND RUBELLA VIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (61)
February 1, 2016 MENINGOCOCCAL GROUP B VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (63)
February 1, 2016 MENINGOCOCCAL OLIGOSACCHARIDE DIPHTHERIA CONJUGATE VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (63)
February 1, 2016 MENINGOCOCCAL POLYSACCHARIDE DIPHTHERIA CONJUGATE VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (63)
February 1, 2016 MENINGOCOCCAL POLYSACCHARIDE VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1b (63)
February 1, 2016 RABIES VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1c (37)
February 1, 2016 TETANUS AND DIPHTHERIA TOXOIDS ADSORBED VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1d (12)
February 1, 2016 VARICELLA VIRUS VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1d (26)
February 1, 2016 ZOSTER VACCINE Drug added, strength added, administration added, restriction added drugs cdl p1d (32)

Changed Drug(s)
Effective Date
Drug Summary of Changes Page(s) Updated
February 1, 2016 DIPHTHERIA/PERTUSSIS/TETANUS VACCINE Restriction added, restriction removed, note removed, administration removed drugs cdl p1a (61)
February 1, 2016 HYALURONIDASE Restriction added drugs cdl p1b (32)
February 1, 2016 IMMUNE GLOBULIN, Rh0 (D), INTRAVENOUS Restriction added

drugs cdl p1b (38)
February 1, 2016 INFLUENZA A (H1N1) VIRUS VACCINE Restriction added drugs cdl p1b (39)
February 1, 2016 PNEUMOCOCCAL VACCINE, 13-VALENT, CONJUGATED Restriction added, strength added, strength removed drugs cdl p1c (28)
February 1, 2016 PNEUMOCOCCAL VACCINE, 23-VALENT, NON-CONJUGATED Restriction added, strength added, strength removed drugs cdl p1c (28)
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24. 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, 2016
NDC Labeler Code Contracting Company's Name
11534 SUNRISE PHARMACEUTICAL, INC.
53436 RELYPSA, INC.
57278 ROCKWELL MEDICAL, INC.
58487 NEW HAVEN PHARMACEUTICALS, INC.
58604 SPROUT PHARMACEUTICALS, INC.
59467 HIKMA AMERICAS
61894 SYMPLMED PHARMACEUTICALS
62332 ALEMBIC PHARMACEUTICALS INC.
64842 TAIHO PHARMACEUTICAL CO. LTD.
67308 DUSA PHARMACEUTICALS, INC.
68992 VELOXIS PHARMACEUTICALS
69171 MERRIMACK PHARMACEUTICALS, INC.
69367 WESTMINSTER PHARMACEUTICALS, LLC
69452 BIONPHARMA, INC.
69656 TESARO INC.
69918 AMRING PHARMACEUTICALS, INC.
70211 TYCHASIS CORPORATION
   
Terminations, effective January 1, 2016
NDC Labeler Code Contracting Company's Name
35501 HUCKABY PHARMACEUTICALS, INC.
68040 PRIMUS PHARMACEUTICALS, INC.
76331 W.H. NUTRITIONALS, LLC

This information is reflected in the following provider manual(s):

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 (6, 8, 11–18)
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25. March 2016 Medi-Cal Provider Seminar

The next Medi-Cal Provider Seminar is scheduled for March 23, 2016, at the Sacramento Marriott in Rancho Cordova, California. Providers can access a class schedule for the seminar by visiting the Provider Training page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the Fiscal Intermediary for Medi-Cal, Xerox State Healthcare, LLC (Xerox) conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative page, enter the zip code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact your Regional Representative, you must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a representative.

Providers are encouraged to bookmark the Provider Training page and refer to it often for current seminar information.

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26. Provider Orientation

Family PACT

Medi-Cal providers applying to become a Family Planning, Access, Care and Treatment (Family PACT) provider are required to attend a Provider Orientation per Welfare and Institutions Code (W&I Code), Section (§) 24005(k). The Family PACT Provider Orientation provides an overview of the Family PACT Program, provider enrollment process, program standards and benefits, and client eligibility and enrollment. Certificates of Attendance are issued at the end of the session.

Solo providers, group providers, or primary care clinics are eligible to apply for enrollment in the Family PACT Program if they currently have a National Provider Identifier (NPI) and are enrolled in Medi-Cal in good standing.

The medical director, physician, nurse practitioner, or certified nurse midwife responsible for overseeing the family planning services to be rendered at the site to be enrolled is eligible to certify the site. Site certifiers shall sign a statement affirming responsibility. State-issued photo identification must be presented upon provider orientation check-in.

Family PACT has implemented a new provider enrollment policy effective February 1, 2016. Some of the highlights of this new policy are:

For more information about the new policy visit the Provider Enrollment (prov enroll) section of the Policies, Procedures and Billing Instructions manual.

Provider Orientation Highlights

Upcoming Provider Orientations

Oakland
February 22, 2016
8:30 a.m. – 4:30 p.m.

The California Endowment
1111 Broadway, 7th Floor
Oakland, CA 94607
Fresno
April 5 and 6, 2016
Two Orientations
8:30 a.m. – 4:30 p.m.

Department of General Services
2550 Mariposa Mall
Fresno, CA 95721
Los Angeles
June 20 and 21, 2016
Two Orientations
8:30 a.m. – 4:30 p.m.

The California Endowments
1000 North Alameda
Los Angeles, CA 90012

For more information about Provider Orientations, please call (916) 324-0389.

Registration
The registration form should be submitted in an electronic format.

To register for an Orientation, providers should:

If you experience problems using the “Submit by Email” button, please fax the registration form to (916) 440-5634 or send as an attachment to ProviderServices@dhcs.ca.gov.

Check-In
Check-in begins at 8:00 a.m. and ends at 8:50 a.m. If you are attending to certify a site, you must check-in no later than 8:50 a.m. and attend the entire orientation to receive a Certificate of Attendance. A late check-in will not be accepted and no exceptions will be made, as Family PACT policy requires the site certifier to attend the entire orientation. Site certifiers must present a State issued photo identification upon check-in.

Xerox State Healthcare, LLC field representatives will be available for questions about billing and claims.

Note:

Individuals representing a clinic or physician group should use the clinic or group National Provider Identifier (NPI), not an individual NPI or license number.

Certificates of Attendance are issued to site certifiers upon completion of a provider orientation. The original certificate is retained by DHCS. Certificates of Attendance are not transferable. A separate certificate is prepared for each provider site.

Although non-certifying provider staff members are encouraged to attend provider orientation sessions to stay current with program policies, procedures, and services, they are not eligible to receive a Certificate of Attendance or certify a service site for enrollment. The provider staff members receive a Proof of Participation.

Contact Information
For more information about the Family PACT Program, please call (800) 942-1054 or visit the Family PACT website.

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27. National Correct Coding Initiative Quarterly Update for January 2016

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 valid for dates of service on or after January 1, 2016.

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

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

MCSS Logo

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails for urgent announcements and other updates shortly, after posting on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form
  2. Enter your email address and ZIP code
  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

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.

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29. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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