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Medi-Cal Update

General Medicine | March 2021 | Bulletin 561

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1. Updated CCS COVID-19 Guidance, CCS FAQs and COVID Vaccine Flexibilities

The Department of Health Care Services (DHCS) recently developed and posted the following documents to the COVID-19 Information for Providers & Partners web page to provide Coronavirus disease (COVID-19) related guidance for the California Children’s Services (CCS) Program:

  1. Updated CCS COVID-19 Guidance

  2. CCS FAQs for COVID-19 Flexibilities

  3. Flexibilities for County Staff during COVID Vaccine Administration

These documents are also available on the CCS Letters web page.

2. Rates for Certain COVID-19 Diagnostic Testing HCPCS Codes Updated

Effective for dates of service on or after January 1, 2021, the base payment amount for HCPCS Codes U0003 (Infectious agent detection by nucleic acid [DNA or RNA]; Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)], amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R), and U0004 (2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV [COVID-19], any technique, multiple types or subtypes [includes all targets], non-CDC, making use of high throughput technologies as described by CMS-2020-01-R), has been adjusted from $100 to $75.

HCPCS Code Description Current Rate New Rate
U0003 SARS Cov-2 COVID-19 Amp prob high throughput $100.00 $75.00
U0004 COVID-19 lab test non-CDC high throughput $100.00 $75.00

Additionally, the codes listed above will be exempt from the 10 percent payment reductions in Welfare and Institutions Code (W&I Code) section 14105.192, as described at Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

An Erroneous Payment Correction (EPC) will be issued for affected claims for codes U0003 and U0004 retroactive to dates of service on or after January 1, 2021.

3. Updates to EWC Forms

Updates have been made to the following Every Woman Counts (EWC) forms:

  • Breast Only Primary Care Provider Covered Procedures Form (DHCS 8471)

  • Breast and Cervical Primary Care Provider Covered Procedures Form (DHCS 8472)

  • Referral Providers Primary Care Provider Covered Procedures Form (DHCS 8473)

The forms can be found at: the Every Woman Counts (EWC) Manuals, Forms and Worksheets page and the Forms page of the Medi-Cal website.

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Clinics and Hospitals
ev woman (36–48)

4. New ICD-10-CM and ICD-10 PCS Diagnosis Codes Related to COVID-19

Effective for dates of service on or after January 1, 2021, the Centers for Medicare & Medicaid Services (CMS) has added new ICD-10-CM codes and ICD-10 PCS codes for diagnoses related to coronavirus disease 2019 (COVID-19). Information and downloads for these codes can be found on the ICD-10 page of the CMS website. Specific billing policy related to this update will be published in a future Medi-Cal Update and Family PACT Update.

5. 2021 CPT Spilt-Bill Update

The 2021 Quarter 1 updates to the Common Procedure Terminology (CPT®) codes are available in the CPT Policy Updates PDF. Only those codes representing current and past Medi-Cal benefits are included in the list of updates.

Split-bill policy for select CPT codes has been updated.

The code additions, changes and deletions are effective for dates of service on or after January 1,2021. Please refer to the HCPCS Level I code books for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics path bil (5–9)
Clinics and Hospitals
General Medicine
medne neu (5); path bil (5–9); radi (7)
Obstetrics path bil (5–9); radi (7)

6. CPT 2021 EWC Correction

The December 2020 Medi-Cal Update incorrectly added CPT® code 57465 (computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect) as a benefit of the Every Woman Counts program.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (24)

7. CCS Program and GHPP Require Separate SAR for Risdiplam

Effective retroactively for dates of service on or after August 1, 2020, the California Children’s Services (CCS) program and the Genetically Handicapped Persons Program (GHPP) require a separate Service Authorization Request (SAR) for risdiplam. This drug is not included in a physician service code grouping (SCG).

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 (8, 9); genetic (10, 11)

8. Sevenfact Added as a Medi-Cal Benefit

Effective for dates of service on or after April 1, 2021, HCPCS code J7212 (injection, factor VIIa [antihemophilic factor, recombinant]-jncw [Sevenfact], 1 mcg) is a Medi-Cal benefit.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Pharmacy
blood (4)
Clinics and Hospitals
General Medicine
blood (4); non ph (15, 29)
Obstetrics
Rehabilitation Clinics
non ph (15, 29)

9. Single-Use Drug/Biological Wastage Now Reimbursable with JW Modifier

Effective for dates of service on or after April 1, 2021, the HCPCS Level II, JW modifier may be used on drug claims to report the amount of drug or biological that is discarded and eligible for payment under the discarded drug policy.

The discarded drug amount is the amount of a single-use vial or other single-use package that remains after administering a dose/quantity of the drug to a Medi-Cal beneficiary. This policy applies to all separately billable drugs that are designated as single-use or single-dose on the FDA-approved label or package insert. Package size can be verified on the FDA website at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/.

JW modifier should not be used for the following:

  • Drugs that are not separately payable, such as packaged Outpatient Prospective Payment System (OPPS) drugs or drugs administered in the Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) setting since they are not generally separately billable

  • Drugs paid under the Part B drug Competitive Acquisition Program (CAP) (the CAP remains on hold and there is currently no list of CAP medications)

  • Claims for hospital inpatient admissions that are billed under the Inpatient Prospective Payment System (IPPS)

  • When the actual dose administered is less than the HCPCS billing unit, since payment will not be made using fractional billing units and billing the discarded amount in addition to the HCPCS unit may result in overpayment

Instructions for billing and documentation:

  • Providers are to bill drug/biological wastage using the JW modifier in addition to documenting the name, dosage, route of administration and National Drug Code (NDC) of the drug/biological on the claim form

  • Providers are to document the discarded drug/biological in the Medi-Cal beneficiary’s medical records, including the date, time and quantity wasted

  • Providers are to bill the discarded drug/biological on a separate claim line with the JW modifier
Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
modif (2–4); modif app (14)
Audiology and Hearing Aids
Durable Medical Equipment
Home Health Agencies/Home and Community-Based Services
Local Education Agency
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
modif app (14)

10. Policy Updates to Certolizumab Pegol

Effective for dates of service on or after April 1, 2021, the Department of Health Care Services (DHCS) is updating policy for HCPCS code J0717 (injection, certolizumab pegol, 1 mg) to include additional indications approved by the Food and Drug Administration (FDA).

Certolizumab pegol, a pegylated anti-TNF (tumor necrosis factor) biologic therapy, is approved to use for the treatment of Crohn’s Disease, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, plaque psoriasis and non-radiographic axial spondyloarthritis.

HCPCS code J0717 may be billed with modifiers SA, UD, U7 and 99.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject drug a-d (43–62); modif used (13)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject drug a-d (43–62); modif used (13); non ph (28)
Pharmacy inject drug a-d (43–62)

11. TAR Criteria Updated for Gene Sequencing

Effective for dates of service on or after April 1, 2021, the Treatment Authorization Requirement (TAR) criteria for CPT® code 81407 (molecular pathology procedure, Level 8) has been updated to remove APOB (apolipoprotein B) full gene sequencing.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (66)

12. National Correct Coding Initiative Quarterly Update for April 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 April 1, 2021.

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

13. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after April 1, 2021, for additions, June 1, 2021, for deletions and February 1, 2020 for one Smart Choice product (UPN 40857950006006) the List of Contracted Incontinence Absorbent Products is updated. Contracted products are added, updated and/or deleted for manufacturers Attends, Cardinal, Secure and Smart Choice. Product descriptions are also updated for one Drylock product (ILI03200) and one Hartmann product (333607).

14. 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.

Effective Date Drug Summary of Changes    Page(s) Updated
March 1, 2021    Bumetanide Drug added,
administration added   
drugs cdl p1a (43),
drugs cdl p4 (20)
March 1, 2021 Diclofenac Sodium Drug added,
administration added
drugs cdl p1a (90),
drugs cdl p4 (28)
March 1, 2021 Flecainide Acetate Drug added,
administration added
drugs cdl p1b (28),
drugs cdl p4 (20)
March 1, 2021    Levalbuterol Drug added drugs cdl p4 (12)
March 1, 2021 Lidocaine Drug added,
administration added
drugs cdl p1b (86),
drugs cdl p4 (28)
March 1, 2021 Sildenafil Citrate Drug added,
administration added,
restriction added
drugs cdl p1d (4),
drugs cdl p4 (19)
March 1, 2021 Tretinoin    Drug added,
administration added
drugs cdl p1d (38),
drugs cdl p4 (28)
Effective Date Drug Summary of Changes    Page(s) Updated
January 1, 2021    Ceritinib Drug added drugs cdl p1a (56)
March 1, 2021    Colesevelam HCL Restriction updated drugs cdl p1a (72)
March 1, 2021    Levalbuterol HCL Restriction removed drugs cdl p1b (81)
March 1, 2021    Levalbuterol Tartrate Restriction removed drugs cdl p1b (82)
March 1, 2021    Tamoxifen Citrate Restriction removed drugs cdl p1d (17)
April 1, 2021    Pramipexole Dihydrochloride Restriction updated drugs cdl p1c (55)

15. Update to the List of Contracted Incontinence Creams and Washes

Effective for dates of service on or after April 1, 2021, TENA Cleansing Cream is added as a contracted wash product for Essity HMS North American, Inc. on the List of Contracted Incontinence Creams and Washes.

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17. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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