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Medi-Cal Update

Inpatient Services | March 2021 | Bulletin 558

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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. 2020-2021 Distinct Part Nursing Facilities – Level B Reimbursement Rate Update

The California Department of Health Care Services (DHCS) has updated the 2020-2021 Medi-Cal reimbursement rates for Distinct-Part Nursing Facilities – Level B (DP/NF-B). The rates are effective for services provided on or after August 1, 2020.

Due to the Coronavirus disease (COVID-19) outbreak, a public health emergency was declared for the United States on January 31, 2020, and a national emergency was declared under the Stafford Act on March 13, 2020. In response to the COVID-19 outbreak, DHCS will temporarily provide an additional 10 percent reimbursement for Long Term Care (LTC) per diem rates. DHCS received federal approval of State Plan Amendment (SPA) 20-0024, effective March 1, 2020, which authorizes temporary additional reimbursement for eligible LTC facilities during the emergency period related to the COVID-19 outbreak. For rate year (RY) 2020-2021, the COVID-19 increased amounts will remain unchanged and will be added to the per diem rates that became effective August 1, 2020.

Upon expiration of the public health emergency or national emergency, whichever occurs first, LTC reimbursements will revert to the RY 2020-2021 annual per diem rates.

Providers should bill using the new rates for dates of service on or after August 1, 2020. Providers do not need to resubmit claims to adjust their payments; the California MMIS Fiscal Intermediaries will process any retroactive rate adjustments for claims paid at the prior rate.

For billing or payment questions, providers may call the Telephone Service Center at 1-800-541-5555, Monday through Friday from 8 a.m. to 5 p.m.

DHCS will notify providers of their DP/NF-B facility specific rates in a separate letter. In the meantime, providers may find their rates posted on the Distinct Part Nursing Facilities, Level B (DP/NF-B) page.

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (2, 5, 9)

3. 2020-2021 Rural Swing Bed Updated Reimbursement Rates

The California Department of Health Care Services (DHCS) has updated the Rural Swing Bed rates for Accommodation Codes 04 (Regular Services) and 05 (Leave of Absence/Bed Hold).

Due to the Coronavirus disease (COVID-19) outbreak, a public health emergency was declared for the United States on January 31, 2020, and a national emergency was declared under the Stafford Act on March 13, 2020. In response to the COVID-19 outbreak, DHCS will temporarily provide an additional 10 percent reimbursement for Long Term Care (LTC) per diem rates. DHCS received federal approval of State Plan Amendment (SPA) 20-0024, effective March 1, 2020, which authorizes temporary additional reimbursement for eligible LTC facilities during the emergency period related to the COVID-19 outbreak. For rate year (RY) 2020-2021, the COVID-19 increased amounts will remain unchanged and will be added to the per diem rates that became effective August 1, 2020.

Upon expiration of the public health emergency or national emergency, whichever occurs first, LTC reimbursements will revert to the RY 2020-2201 annual per diem rates.

Rural Swing Bed rates are exempt from the Assembly Bill (AB) 97, 10 percent payment reduction, but are subject to the AB 97 rate freeze at the reimbursement rate established in 2008-2009 including any applicable add-ons. However, retroactive to September 1, 2013, Distinct-Part Nursing Facilities – Level B (DP/NF-B) located in designated rural or frontier areas are exempt from the AB 97 rate freeze.

  1. Effective August 1, 2020, the Rural Swing Bed rates in hospitals located in designated rural/frontier areas with DP/NP-Bs are as follows:
Rural Swing Bed (Exempt from AB 97 Rate Freeze)
Effective 8/1/2020
Accommodation Code Temporary Rate
04 $522.77
05 $514.02

The temporary rate of $522.77 includes 2020 $1.72 unfrozen add-ons and $43.67 temporary COVID-19 increase.

The temporary rate of $514.02 is $522.77 minus 2020 Leave of Absence/Bed Hold rate of $8.75

  1. Effective August 1, 2020, the Rural Swing Bed rates for rural hospitals that do not have a DP/NF-B are not exempt from the AB 97 rate freeze
Rural Swing Bed (Not Exempt from AB 97 Rate Freeze)
Effective 8/1/2020
Accommodation Code Temporary Rate
04 $344.27
05 $335.52

The temporary rate of $344.27 includes 2008 rate of $305.15 plus 2020 $7.91 frozen add-ons plus $31.21 temporary COVID-19 increase.

The temporary bed hold rate is $344.27 minus 2020 Leave of Absence/Bed Hold amount of $8.75.

Providers do not need to resubmit claims to adjust their payments. The California MMIS Fiscal Intermediaries will process any retroactive rate adjustments for claims paid at the prior rate.

For billing or payment questions, providers may call the Telephone Service Center at 1-800-541-5555, Monday through Friday from 8 a.m. to 5 p.m.

Providers may find the Rural Swing Bed rates posted on the Rural Swing Bed page of the DHCS website.

Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (2, 5, 9)

4. 2020-2021 Administrative Day Reimbursement Rate Update

The California Department of Health Care Services (DHCS) has updated the Statewide Administrative Day (AD) rates including the AD rates for Distinct Part Nursing Facility Level B’s (DP/NF-B), effective for the following periods:

Administrative Day 2020-21 Temporary COVID-19 Increased Rate
Effective Date Temporary Rate
8/1/2020 $626.60

Note: In accordance with California Code of Regulations (CCR), Title 22, Sections 51542 and 51511, a DP/NF-B of an acute care hospital will receive the lesser of its projected costs or the DP/NF-B median rate as their AD rate. Acute care hospitals without a DP/NF-B will receive the AD rate indicated above.

Providers should bill using the new rate immediately for dates of services on or after August 1, 2020.

Due to the Coronavirus disease (COVID-19) outbreak, a public health emergency was declared for the United States on January 31, 2020, and a national emergency was declared under the Stafford Act on March 13, 2020. In response to the COVID-19 outbreak, DHCS will temporarily provide an additional 10 percent reimbursement for Long Term Care (LTC) per diem rates. DHCS received federal approval of State Plan Amendment (SPA) 20-0024, effective March 1, 2020, which authorizes temporary additional reimbursement for eligible LTC facilities during the emergency period related to the COVID-19 outbreak. For rate year (RY) 2020-2021, the COVID-19 increased amounts will remain unchanged and will be added to the per diem rates that became effective August 1, 2020.

Upon expiration of the public health emergency or national emergency, whichever occurs first, LTC reimbursements will revert to the RY 2020-2021 annual per diem rates.

Providers do not need to resubmit claims to adjust their payments. The California MMIS Fiscal Intermediaries will process any retroactive rate adjustments for claims paid at the prior rate.

For billing or payment questions, providers may call the Telephone Service Center at 1-800-541-5555, Monday through Friday from 8 a.m. to 5 p.m.

DHCS will notify providers of their DP/NF-B facility specific rates in a separate letter. In the meantime, providers may find their rates posted on the LTC Reimbursement page of the DHCS website.

Provider Manual(s) Page(s) Updated
Inpatient Services admin (4, 9)
Long Term Care rate facil diem (2)

5. 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.

6. 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.

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. 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.

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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