Medi-Cal Logo

Medi-Cal Update

General Medicine | August 2022 | Bulletin 578

Print Medi-Cal Update Print Icon

1. FDA Approves COVID-19 Vaccine for Children 6 Months and Up

Effective for dates of service on or after June 17, 2022, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorizations (EUA) for the Pfizer-BioNTech and Moderna COVID-19 vaccines with the following updates:

Pfizer-BioNTech COVID-19 Vaccine

The FDA amended the EUA to include use of the vaccine in individuals 6 months through 4 years of age.

Moderna COVID-19 Vaccine

The FDA amended the EUA to include use of the vaccine in individuals 6 months through 17 years of age.

For the most current information regarding Medi-Cal’s COVID-19 Response, see the COVID-19 Medi-Cal Response page on the Medi-Cal Providers website.

For the most current information regarding Pfizer-BioNTech COVID-19 and Moderna COVID-19 vaccines, see the Pfizer-BioNTech COVID-19 page or Moderna COVID-19 page on the Medi-Cal Provider website.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (39–52); immun cd (5–8)

2. New Approval Messages for COVID-19 Uninsured Group User Guide

Effective August 3, 2022, the approval messages for individuals granted COVID-19 Uninsured Group (UIG) coverage will be updated. The update provides additional information for beneficiaries on ways to apply for full coverage and removes the reference to a 12-month limit for COVID UIG program eligibility. Eligibility for the COVID-19 UIG program will end on the last day of the month in which the Public Health Emergency ends regardless of when that eligibility was granted.

For more information on COVID-19 Uninsured Group coverage, refer to the COVID-19 Uninsured Group Web Portal User Guide on the COVID-19 Medi-Cal Response page on the Medi-Cal Providers website.

3. Levofloxacin Added as Clinic Benefit for Family PACT and Medi-Cal Programs

Effective for dates of service on or after September 1, 2022, oral levofloxacin is a family planning-related clinic benefit for the treatment of Sexually Transmitted Infections (STIs) for the Family Planning, Access, Care and Treatment (Family PACT) and Medi-Cal programs in accordance with the Centers for Disease Control and Prevention (CDC), Sexually Transmitted Infections Treatment Guidelines, 2021.

4. Rate Update for Contraceptive Vaginal Gel

Effective for dates of service on or after October 1, 2021, the rate for HCPCS code A4269 (contraceptive supply, spermicide [e.g., foam, gel], each) with modifier U5 for contraceptive vaginal gel, Phexxi® (lactic acid, citric acid, and potassium bitartrate) is $282.54.

An Erroneous Payment Correction (EPC) will be implemented for affected claims from date of service on or after October 1, 2021, to the implementation date of this policy.

Provider Manual(s) Page(s) Updated
Family PACT drug onsite (1)

5. Radiology Reimbursement Rates Updated Retroactively

Effective retroactively for dates of service on or after January 1, 2022, radiology reimbursement rates are updated.

In pursuant to Senate Bill 853 (Chapter 717, Statutes of 2010), as codified at Welfare and Institutions Code section 14105.08, the Department of Health Care Services (DHCS) has adjusted Medi-Cal reimbursement rates for radiology services so they do not exceed 80 percent of the corresponding Medicare rate. DHCS has authority per State Plan Amendment 22-0006 to adjust Medi-Cal Fee-for-Service provider reimbursement rates for Radiology services.

The updated radiology reimbursement rates are available on the Medi-Cal Rates page.

An Erroneous Payment Correction (EPC) will be implemented to reprocess 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 paid base on the previous Medi-Cal rate. 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.

6. Family PACT and Medi-Cal Programs End Date Essure

Effective for dates of service on or after September 1, 2022, Essure is end-dated under the Family Planning, Access, Care and Treatment (Family PACT) and Medi-Cal family planning programs when billed with ICD-10-CM code Z30.2 (encounter for sterilization).

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ster (17–21); surg bil mod (1); tar and non cd5 (35)
Family PACT ben fam (33–37); ben grid (12–14, 52); claim cms (11–15)
Inpatient Services ster (17–21); tar and non cd5 (35)

7. TAR No Longer Required for Select CPT Codes

Effective for dates of service on or after September 1, 2022, assistant surgeon services for the following CPT® codes do not require a Treatment Authorization Request (TAR) because a TAR is already required for the primary surgeon services:

  • 22856: Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical

  • 23473: Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

  • 23474: Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

  • 48160: Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells

  • 66920: Removal of lens material; intracapsular

8. Reminder: Annual Cognitive Assessment Added as a Medi-Cal Benefit

As previously announced in the article titled, “Annual Cognitive Assessment Added as a Medi-Cal Benefit,” effective for dates of service on or after July 1, 2022, CPT® code 1494F (cognition assessed and reviewed [DEM]) is added as a Medi-Cal benefit for recipients 65 years of age and older who do not have Medicare coverage. CPT code 1494F has a frequency limit of once per year, per same provider.

For reimbursement of an annual cognitive health assessment, providers must do all of the following:

  • Complete the Department of Health Care Services (DHCS) Dementia Care Aware cognitive health assessment training prior to conducting the brief cognitive health assessment

  • Administer the annual cognitive health assessment as a component of an Evaluation and Management (E&M) visit including, but not limited to, an office visit, consultation or preventive medicine service. An annual cognitive health assessment shall identify signs of Alzheimer’s disease or dementia, consistent with the standards for detecting cognitive impairment under the federal Centers for Medicare and Medicaid Services and the recommendations by the American Academy of Neurology.

  • Bill CPT code 1494F on an additional claim line.
Note: Recipients with Medicare coverage are not eligible for this service since Medicare recipients have access to this service through the annual wellness visit. CPT code 1494F is only reimbursable for beneficiaries 65 years of age and older who do not have Medicare coverage.
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (38); medi non cpt (1)

9. Reminder: Discontinued and Invalid Z Modifiers

This is a reminder that providers should not be billing with certain Z modifiers that haven’t been in use ever since they were discontinued and removed from the provider manual in March, 2011. Any use of the following modifiers will be denied:

  • ZA

  • ZD

  • ZE

  • ZF

  • ZG

More information on approved and disapproved modifiers can be found in the Modifiers: Approved List section of the provider manual.

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment and Medical Supplies
General Medicine
Home Health Agencies/Home and Community-Based
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Rehabilitation Clinics
Therapies
Vision Care
modif used (6–9)

10. Update: Paper RADs And No Pay Documents

On July 14, 2022, a newsflash titled “Paper RADs And No Pay Documents Will No Longer Be Mailed Due To Supply Chain Issues” was published. Paper Remittance Advice Details (RADs), Electronic Fund Transfer (EFT) and No Pay documents were previously expected to discontinue effective July 18, 2022, however the State Controller’s Office (SCO) will continue printing until the supply is consumed.

The Department of Health Care Services (DHCS) still plans to end mailed RADs and No Pay documents in the future. Providers who have not yet transitioned to the PDF RADs (which includes the embedded financial summary information) are strongly encouraged to do so at this time.

Benefits of PDF RADs:

  • The PDF RAD (and embedded financial summary information) is available earlier than paper RADs and financial summaries.

  • The PDF RADs and financial summary contains all the information of paper RADs and financial summaries.

  • There is no charge for this online service.

  • Up to six calendar weeks of current RADs are available for immediate download. In addition, a historical RAD base has been built, and up to three years of historical RADs are available within one business day of a request.

  • Printed versions of the online PDF RADs are adequate to submit as supporting documentation with Claims Inquiry Forms (CIFs) and Appeal Forms.

  • Help California go green by no longer receiving paper RADs.

Online PDF RADs and Medi-Cal Financial Summary Enrollment Instructions:

Quick & Easy Access:

  1. Log in to your Medi-Cal account on the Medi-Cal Providers website under the Transactions tab. (Providers must have a signed Med-Cal Point of Service [POS] Network/Internet Agreement form on file)

  2. Click on the “Other” tab

  3. Click on the “Remittance Advice Detail (RAD)” link

Once enrolled, the PDF RAD and Medi-Cal Financial Summary are accessible on the Medi-Cal Providers website under the Transaction Services page. To access the transaction, providers must have a signed Medi-Cal Point of Service (POS) Network/Internet Agreement form on file, an NPI and PIN.

For any questions regarding PDF RAD access or completion of the Medi-Cal Point of Service (POS) Network/Internet Agreement, contact the Telephone Service Center (TSC) at 1-800-541-5555.

11. October 2022 Medi-Cal Provider “Coffee Break” Event

Outreach and Education (O&E), along with the Department of Health Care Services (DHCS) is offering a “Coffee Break” event in October for category specific topics.

Topics discussed will include the following:

Topic Date
Remittance Advice Details October 4 and October 18
Medi-Cal Resources October 4 and October 18
Claims Follow-up October 5 and October 19
Eligibility/Share of Cost (SOC) October 5 and October 19
Lab Services October 6 and October 20
Home Health/Early and Periodic Screening Diagnostic and Treatment (EPSDT) October 6 and October 20
Medical Transportation October 11 and October 25
Durable Medical Equipment (DME) October 11 and October 25
Inpatient Obstetrics (OB) October 12 and October 26
Family Planning, Access, Care and Treatment (Family PACT) October 12 and October 26
California Children's Hospital (CCS)/Genetically Handicapped Person's Program (GHPP) October 13 and October 27
Obstetrics (OB)/Comprehensive Perinatal Services Program (CPSP) October 13 and October 27

Providers may visit the Medi-Cal Learning Portal (MLP) to view available coffee break times and to register in the Event Calendar.

Providers are encouraged to bring questions relating to the “Coffee Break” session topic. This is an open forum, therefore, claim examples are not needed for this event.

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

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

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 shortly after urgent announcements and other updates post 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 and select a subscriber type

  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.

13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



Note:
Download PDF (Portable Document Format) reader from the Web Tool Box.