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Medi-Cal Update

General Medicine | March 2022 | Bulletin 573

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1. Frequency Limits Updated for COVID-19 Related Laboratory Codes

Effective retroactively for dates of service on or after the effective dates of the codes listed below, the frequency limit for select COVID-19 related laboratory codes has been updated. See the table below for current frequency limits and the effective date.

Procedure Code Frequency Limit (per day, any provider) Effective Date
86328 3 7/1/2020
86408 1 1/1/2021
86409 1 1/1/2021
86413 3 1/1/2021
86769 3 7/1/2020
87426 3 1/1/2021
87428 3 7/1/2021
87635 2 7/1/2020
87636 3 1/1/2021
87637 3 1/1/2021
87811 3 1/1/2021
C9803 2 10/1/2020
G2023 2 7/1/2020
G2024 2 7/1/2020
U0001 2 7/1/2020
U0002 2 7/1/2020
U0003 2 7/1/2020
U0004 2 7/1/2020

Medical justification with a Treatment Authorization Request/Service Authorization Request (TAR/SAR) to override the frequency limit for these laboratory codes may be allowed.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriation and adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

For additional information regarding policy for these select COVID-19 laboratory codes, please refer to the appropriate Part 2 Provider Manual sections.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path micro (10–14); presum bill (5–8, 13, 15–18)

2. Providers Holding Submissions of Claims for COVID-19 Vaccine Administration May Now Submit

Effective retroactively for dates of service on or after the respective dates for each approved COVID-19 vaccine, providers working with individuals in the following populations may receive reimbursement for administration of the coronavirus disease 2019 (COVID-19) vaccines:

  • Recipients in the Tuberculosis Program

  • Family PACT recipients

  • COVID-19 Uninsured Group recipients

Refer to the webpages below for billing guidance and effective dates for each vaccine:

Effective until December 31, 2022, Medi-Cal will waive the timeliness standard for vaccination administration claims by these providers when claims are submitted or resubmitted (electronically, or via hard copy) with the following:

  • Delay Reason Code “10”

  • Documentation indicating that the COVID-19 vaccine was administered are in the Remarks area of the submitted claim (for example, “COVID Vaccine administration”)

An Erroneous Payment Correction (EPC) will be implemented to reprocess any previously denied claims that were submitted by affected providers for the administration of an applicable COVID-19 vaccine. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described earlier in this article.

For instructions on how to submit or resubmit a claim with a delay reason code, see the following resources:

Previously, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) providers were advised to hold claim submission for the administration of COVID-19 vaccines. FQHC and RHC providers are still advised to continue to hold claims. Providers will be notified when Medi-Cal is ready to accept claims from these providers.

3. Laboratory/Pathology Non-Specific ICD-10-CM Codes Update

Effective for dates of service on or after April 1, 2022, providers may now submit claims for the following non-specific ICD-10-CM diagnosis codes when ordering billing for laboratory procedures: Z00.00, Z00.5, Z00.6, Z00.8, Z01.00, Z01.10, Z01.89, Z02.1and Z02.3.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path bil (1); path surg (2)
Chronic Dialysis Clinics path bil (1)

4. Clinical Laboratory Rate Adjustment Effective July 1, 2021

Update: Rates for select laboratory codes were erroneously updated in the original rate listing on the Medi-Cal Rates page (titled “Clinical Laboratory Rates, effective July 1, 2021, updated in accordance with State Plan Amendment 21-0052”). A follow-up article, titled “Clinical Laboratory Services Rate Adjustment Effective July 1, 2021” published in the March General Bulletin, and specifies what CPT or HCPCS codes were affected by this incorrect update.

The Department of Health Care Services (DHCS) adjusted certain Medi-Cal reimbursement rates for clinical laboratory or laboratory services, effective July 1, 2021. Assembly Bill 133 (Chapter 143, Statutes 2021, as codified at Welfare and Institutions Code, Section 14105.222(c), requires DHCS to update reimbursement rates for clinical laboratory or laboratory services effective July 1, 2021, at the rates that were in effect and approved in the Medi-Cal State Plan as of December 31, 2019.

DHCS also published an accompanying rate listing on the Medi-Cal Rates web page that includes the impacted rates and effective dates. No provider action is needed.

5. Changes to National Correct Coding Initiative January 2022 First Quarter Update

The Centers for Medicare & Medicaid Services (CMS) issued a third set of replacement files for National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits for the first quarter of 2022. The mandatory national edits were incorporated into the Medi-Cal claims processing system and were effective for claims received on or after January 1, 2022.

No action is required by providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess the affected claims, including those that were appropriately submitted based on the guidance published in this article, but erroneously adjudicated because Medi-Cal had not yet implemented the system changes to support appropriate adjudication.

More information on NCCI and this latest update can be found on The National Correct Coding Initiative in Medicaid web page.

6. National Correct Coding Initiative Quarterly Update for March 2022

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 claims received on or after April 1, 2022.

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

7. June Virtual Claims Assistance Room (CAR) Room Event

Receive free one-on-one billing assistance at our Virtual Claims Assistance Room (CAR) event scheduled for the month of June.

There are multiple morning and afternoon sessions available. Providers must register through the Medi Cal Learning Portal Event Calendar.

Reminder: First time users must complete a one-time registration. Registration directions for these sessions are in a short video in the descriptive text under the “Provider Seminars and Webinars” tile on the Medi-Cal Learning Portal homepage.

Providers are encouraged to bring their more complex billing issues to a Provider Field Representative for individual assistance.

For additional assistance, please contact the Telephone Service Center (TSC) at 1-800-541-5555.

8. Postpartum Care Expansion for Medi-Cal and MCAP Beneficiaries

As part of the American Rescue Act Plan (ARPA), effective April 1, 2022, an individual eligible for pregnancy and postpartum care services under Medi-Cal or the Medi-Cal Access Program (MCAP) is entitled to an additional ten months of postpartum coverage at the end of their 60-day postpartum period for a total 12 months of postpartum coverage. This coverage shall include the full breadth of medically necessary services through the pregnancy and postpartum period.

With this expansion, eligibility for the 12 months of postpartum coverage is granted to any individual in an aid code where postpartum services are a covered benefit.

For more information regarding the ARPA postpartum care expansion (PCE), see the Pregnancy web page on the Medi-Cal Providers website. The web page includes flyers that may be distributed to beneficiaries eligible for the ARPA PCE benefit: This article was originally published on September 16, 2021. It has been republished to continue to bring it to providers’ attention. No additional updates have been made since the original publication with the exception of the paragraph above.

Questions concerning this expansion of postpartum care should be sent to pregnancy@dhcs.ca.gov.

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10. Provider Manual Revisions



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