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Medi-Cal Update

Hospice Care Program | April 2022 | Bulletin 571

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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. 2022 HCPCS Quarter 2 Update

The 2022 quarter 2 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the HCPCS Policy Updates PDF. The code additions, changes and deletions are effective for dates of service on or after April 1, 2022 (unless otherwise specified).
Only those codes representing current and past Medi-Cal benefits are included in the list of updates. Please refer to the HCPCS Level I and II code books for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
AIDS Waiver Program modif app (2, 3, 11, 12)
Audiology and Hearing Aids blood (14–16); immun (50–63, 60–62); immun cd (1, 3, 4); inject cd list (2, 3, 6, 7, 16, 21, 22, 23, 25, 26); inject drug a-d (12, 13, 20, 77–80); inject drug n-r (30, 31, 34, 36–41); inject drug s-z (18); modif app (2, 3, 11, 12); modif used (14, 15)
Clinics and Hospitals
General Medicine
blood (14–16); chemo drug a-d (37); chemo drug e-o (30); chemo drug p-z (30–32, 41); immun (50–63, 60–62); immun cd (1, 3, 4); inject cd list (2, 3, 6, 7, 16, 21, 22, 23, 25, 26); inject drug a-d (12, 13, 20, 77–80); inject drug n-r (30, 31, 34, 36–41); inject drug s-z (18); modif app (2, 12); modif used (14,15); non ph (10, 14, 15, 17, 29, 30, 32); ophthal (8, 9, 23, 24, 30–32); presum bill (3, 13, 16–18, 21); prop lab (21, 24, 62–64); radi dia (22, 23); surg cardio (7); surg integ (4, 6); surg muscu (2, 3); tar and noncd0 (41, 42)
Durable Medical Equipment dura cd fre (6, 11); dura other (16–18, 23); modif app (2, 3, 11, 12); tax (23, 44)
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Vision Care
modif app (2, 3, 11, 12)
Inpatient Services tar and noncd0 (41, 42)
Obstetrics immun (50–63, 60–62); immun cd (1, 3, 4); inject cd list (2, 3, 6, 7, 16, 21, 22, 23, 25, 26); inject drug a-d (12, 13, 20, 77–80); inject drug n-r (30, 31, 34, 36–41); inject drug s-z (18); modif app (2, 3, 11, 12); modif used (14, 15); non ph (10, 14, 15, 17, 29, 30, 32); presum bill (3, 13, 16–18, 21); prop lab (21, 24, 62–64); radi dia (22, 23); tar and noncd0 (41, 42)
Orthotics and Prosthetics dura cd fre (6, 11); modif app (2, 3, 11, 12); tax (23, 44)
Pharmacy dura cd fre (6, 11); dura other (16–18, 23); immun (50–63, 60–62); immun cd (1 ,3 ,4); inject cd list (2, 3, 6, 7, 16, 21, 22, 23, 25, 26); inject drug a-d (12, 13, 20, 77–80); inject drug n-r (30, 31, 34, 36–41); inject drug s-z (18); presum bill (3, 13, 16–18, 21); tax (23, 44)
Rehabilitation Clinics immun (50–63, 60–62); immun cd (1, 3, 4); inject cd list (2, 3, 6, 7, 16, 21, 22, 23, 25, 26); inject drug a-d (12, 13, 20, 77–80); inject drug n-r (30, 31, 34, 36–41); inject drug s-z (18); modif app (2, 3, 11, 12); modif used (14,15); non ph (10,14, 15, 17, 29, 30, 32)
Therapies dura cd fre (6, 11); modif app (2, 3, 11, 12)

3. Older Adult Expansion into Full Scope Medi-Cal

Beginning May 1, 2022, a new law in California will provide adults 50 years of age or older access to full scope Medi-Cal services and immigration status does not matter. All other Medi-Cal eligibility rules, including income limits, will still apply. This initiative, called the Older Adult Expansion, is modeled after Senate Bill 75 and the Young Adult Expansion, which provided full scope Medi-Cal to all eligible children and young adults under the age of 26 regardless of immigration status.

To support the implementation of this initiative, DHCS has created a dedicated Older Adult Expansion web page. The web page currently hosts the following type of information, but the resources on this page will continue to grow as the Older Adult Expansion evolves:

  • A PowerPoint presentation sharing the roadmap to the Older Adult Expansion to Medi-Cal stakeholders,

  • Frequently Asked Questions (FAQ), and

  • First notice, General Information Notice, to Beneficiaries regarding their expansion of benefits.

Providers finding themselves working with beneficiaries who ask about the Older Adult Expansion may leverage these resources for educational purposes.

County offices or other Medi-Cal stakeholders seeking specific policy guidance regarding the Older Adult Expansion may find more information posted in ACWDL 21-13, located on the DHCS website in the All County Welfare Directors’ Letters (ACWDL) page.

Additionally, county offices seeking global outreach language to promote this expansion, may find preliminary messaging in MEDIL 22-02, on the Medi-Cal Eligibility Division Information Letter (MEDIL) web page. The global outreach language currently available includes messaging that can be used in various forms of outreach including social media posts, call scripts, and county website content.

For all other questions related to the Older Adult Expansion, please feel free to contact DHCS at OlderAdultExpansion@dhcs.ca.gov.

4. 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.

5. Update to Provider Manual Terminology to Remove “Alien”

In accordance with Assembly Bill 1096 (Luz Rivas, Chapter 296, Status of 2021), the Medi-Cal Provider Manual is updated to replace the word “alien” with language more reflective of the present legal terminology, such as “non-citizen.”

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Heroin Detoxification
Home Health Agencies/Home and
Community-Based Services
Hospice Care Program
Rehabilitation Clinics
medi cr op (23, 26)
Audiology
Chiropractic
Durable Medical Equipment
General Medicine
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Therapies
medi cr cms (18, 20)
Inpatient Services medi cr ip (17, 19)
Long Term Care medi cr ltc (8, 12)
Vision Care medi cr vc (13)

6. Medi-Cal Rx Billing Policy for Physician Administered Drugs

The Department of Health Care Services (DHCS) continues to receive reports of impeded access to physician administered drugs (PADs) – including chemotherapeutic agents, anti-rejection medications for organ transplants, and long-acting contraceptives – by providers who believe PADs are a pharmacy benefit and billable to Medi-Cal Rx. The bulletin clarifies how PADs should be billed under Medi-Cal Rx.

  • PADs are typically non-self-administered medications dispensed by a health care professional outside of a pharmacy setting. PADs are always a medical benefit that should be submitted by the medical provider on a medical claim to either the fee-for-service (FFS) fiscal intermediary or a managed care plan (MCP) as applicable. MCPs or their contracted agents cannot reassign PAD claims across the board, either in full or in part, to be processed through Medi-Cal Rx.

  • Depending on the medical necessity, there are few exceptions for a pharmacy provider to order, fill, and bill a non-self-administered drug and send it to an administering provider to dispense the drug appropriately. Most of these exceptions require a pharmacy prior authorization (PA) justifying the medical necessity as to why the medically administered drug needs to be billed as a pharmacy claim. The claim can only be billed through Medi-Cal Rx with an approved PA.

  • PA approvals of PADs billed by pharmacy providers are not intended to replace PAD coverage as a medical benefit. PADs will always remain a medical benefit even when they are also available as a pharmacy benefit on a case-by-case basis.

  • Medi-Cal beneficiaries should not be directed to go to a pharmacy to obtain PADs unless the individual case is a warranted exception as described above.

7. New Electronic Claim Resubmission Helps Providers Avoid Paper CIFs/Appeals

Providers can electronically resolve a claim denial or incorrect payment for 837I (Institutional) and 837P (Professional) electronic claims. By resubmitting the claim with either frequency type code “7” (replacement of prior claim) or “8” (void/cancel of prior claim), there is no longer a need to adjust claims using paper Claims Inquiry Forms (CIFs) or Appeal Forms with accompanying Remittance Advice Details (RADs) to show proof of previous claim payment or denial. Electronic claim resubmission is not available for pharmacy claims.

The ANSI X12 v.5010 837 electronic transactions claim format allows a provider to initiate changes to already-adjudicated claims. The 837 Implementation Guides refer to the National Uniform Billing Data Element Specifications Loop 2300 CLM05-3 for explanation and usage. In the 837 formats, the codes are called “claim frequency codes.”

Replacement and void claims can be sent in the same batch as new claims.

Electronic replacement claims must be submitted within six months of the previous claim payment or denial. Providers may submit an electronic follow-up claim even if the original was a paper claim. Claims for which a CIF or appeal are already in progress must not be electronically resubmitted. Claims for which a CIF or appeal is in progress will be denied.

The following chart outlines the use of codes “7” and “8.”

Claim Frequency Code/Definition Use Filing Guidelines Result
7
Replacement of Prior Claim
Use to replace a claim line or entire claim in an already adjudicated paid or denied claim (see following instructions per claim type) File the claim line or entire electronic claim including all services for which reconsideration is requested Medi-Cal will adjust the original claim. The corrections submitted will be reflected on the 835 Transaction and/or paper Remittance Advice Details (RAD) and other standard claim response vehicles
8
Void/Cancel of Prior Claim
Use to eliminate an already adjudicated claim for a specific provider, recipient and date of service (see following instructions per claim type) File the claim electronically and include all claims data and charges that were on the original claim Medi-Cal will void the original claim from history based on request, which will be reflected on the 835 Transaction and/or paper RAD and other standard claim response vehicles

Frequency Type Code ‘7’

Electronic allied health, long term care, medical services, obstetric, outpatient and vision care claims resubmitted with Frequency Type code “7” (replacement claim):

  • Are used to modify only one claim line. They cannot be used to replace multiple original claim lines.

  • A separate replacement claim transaction must be performed for each claim line being replaced. For example, to replace all five lines of an outpatient claim, the submitter must submit five separate transactions.

  • Must contain corrected information for the original claim.

  • Must include the 13-digit Claim Control Number (CCN) from the original paid claim. For the claim to be considered for full reimbursement, the RAD date for the previous claim payment or denial must be within six months of the date the replacement claim was submitted.

Electronic inpatient claims resubmitted with Frequency Type code “7” (replacement claim):

  • Replace the entire inpatient care claim.

Frequency Type Code ‘8’

Electronic long term care, medical services, outpatient and vision care claims resubmitted with Frequency Type code “8,” (void/cancel of prior claim):

  • Must include the 13-digit CCN from the original paid claim.

  • Serve as a full void for one claim line only. Multiple original claim lines cannot be voided with one void claim transaction.

  • A separate void claim transaction must be performed for each claim line being voided. For example, to void all five lines of an outpatient claim, the submitter must submit five separate transactions.

Electronic inpatient claims resubmitted with Frequency Type code “8” (void/cancel of prior claim):

  • Void the entire inpatient care claim.

Errors to Avoid

Providers should pay attention to the instructions above that certain claim types can replace or void one claim line only. Additionally, the CCN of the original claim is the proper information to insert in the REF segment.

Correct CCN for Crossover Claims

Providers resubmitting a Medicare to Medi-Cal crossover claim should take care to enter the CCN from the Medi-Cal claim they are resubmitting and not the CCN from the Medicare claim.

Claim Attachments

Attachments required with the initial claim submission are required for replacement claim submissions. Copies of claims initially submitted on paper are not needed. Information from the paper claim will already have been keyed into the claims processing system.

No attachments are required when voiding a claim.

Information about submitting attachments for electronic claims is available in the Billing Instructions: Acceptable Claims, Attachments and ASC X12N 835 v.5010 Transactions section of the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual, specifically under the following headings:

  • “Supporting Documentation – Attachments”

  • “Attachment Control Form: Required and Optional Fields”

  • “Attachment Control Form (ACF) Guidelines”

Associated RAD Code and Correlation Table Update

The following Remittance Advice Details (RAD) message has been added in the Part 1, RAD Repository, provider manual section to help providers reconcile claims submitted using claim frequency code “7.” (The claim frequency code is the third digit of the “Type of Bill” Code.)

Code Message
9174 Computer Media Claims (CMC) replacement submitted after six months of referred claim Remittance Advice Details (RAD) is not payable

Reimbursement

If the initial adjudicated claim was subject to a reimbursement reduction due to late claim submission, then reimbursement for the resubmitted claim also will be reduced.

Reference

Providers may wish to save a copy of this article for future reference.

Provider Manual(s) Page(s) Updated
Part 1 appeal (1); cif (1); elect (3–5); RAD Repository
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Community-Based Adult Services
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Multipurpose Senior Services Program
Rehabilitation Clinics
ub sub (2, 6)

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