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Medi-Cal Update

Inpatient Services | April 2021 | Bulletin 559

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1. CCS Service Code Groupings Update

The following codes will be added to the California Children’s Services (CCS) Service Code Groupings (SCGs).

Added Codes

Effective Date Codes SCGs
January 15, 2021 CPT Codes 87428, 87636, 87637, 87811 and HCPCS Code G2012 01, 02
January 15, 2021 CPT Codes 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171 02
January 15, 2021 HCPCS Codes L7510, L8621, L9900 04
January 15, 2021 HCPCS Code Q4081 09

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Community-Based Services
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and
Local Educational Agency
Inpatient Services
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (1, 2, 21, 23, 32, 34, 46)

2. Medi-Cal Coverage Under the COVID-19 Public Health Emergency

Under the continuous coverage requirements in the federal Families First Coronavirus Response Act (FFCRA), all Medi-Cal beneficiaries are maintained in their current aid codes until end of the coronavirus disease 2019 (COVID-19) public health emergency (PHE). As a reminder, individuals in pregnancy-related aid codes continue to remain eligible for non-pregnancy services, as appropriate, under current COVID-19 PHE protections. Providers are advised to continue submitting claims with applicable diagnosis codes.

Questions concerning eligibility under pregnancy-related aid codes during PHE should be sent to pregnancy@dhcs.ca.gov.

3. 2021 HCPCS Q2 Update

The 2021 Quarter 2 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the HCPCS Policy Updates PDF. Only those codes representing current and past Medi-Cal benefits are included in the list of updates.

The code updates are effective for dates of service on or after April 1, 2021. Please refer to the HCPCS Level I and II code book for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Audiology speech cd (2, 3)
Chronic Dialysis Clinics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30)
Clinics and Hospitals
General Medicine
chemo drug a-d (13, 22–24); chemo drug p-z (27, 28); immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); medne tele (10, 12); modif used (11–14); non ph (10, 13–15, 30); presum bill (19); prop lab (1, 22, 57–59); radi dia (22); radi nuc (7); surg urin (5); tar and non cd0 (32)
Community-Based Adult Services
Therapies
occu cd (1); once (1–3); phys cd (3); speech cd (2, 3)
Inpatient Services tar and non cd0 (32)
Obstetrics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30); presum bill (19); prop lab (1, 22, 57–59); radi dia (22); radi nuc (7); surg urin (5); tar and non cd0 (32)
Pharmacy immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); presum bill (19)
Rehabilitation Clinics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30); occu cd (1); once (1–3); phys cd (3); speech cd (2, 3)

4. Hereditary Retinal Disorders is a Medi-Cal Benefit

Effective for dates of service on or after May 1, 2021, the Department of Health Care Services (DHCS) has updated CPT® code 81434 (hereditary retinal disorders [e.g., retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy], genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR and USH2A) from being a non-benefit to a benefit.

A Treatment Authorization Request (TAR) for code 81434 requires documentation of the following criteria:

  • Patient has a clinical diagnosis of retinal dystrophy (retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy) and

  • The decision for gene therapy is contingent on the test results

CPT code 81434 has a frequency limit of once in a lifetime and the allowable modifiers are 33, 90 and 99. The age and gender coverage are retained.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics modif used (4)
Clinics and Hospitals
General Medicine
Obstetrics
modif used (4); non ph (9); once (9); path molec (76); tar and non cd8 (10)
Long-Term Care tar and non cd8 (10)
Rehabilitation Clinics modif used (4)

5. Erroneously Published ICD-10-PCS Codes in Provider Manual

The following ICD-10-PCS codes were removed from the Part 2 Inpatient Provider Manual section, Obstetrics: Revenue Codes and Billing Policy for DRG-Reimbursed Hospitals, as they were inappropriately listed for the billing instructions present in the manual section:

  • 3E030VJ

  • 3E033VJ

  • 3E040VJ

  • 3E043VJ

  • 3E050VJ

  • 3E053VJ

  • 3E060VJ

  • 3E063VJ

  • 3E0DXGC

Providers who believe they received an erroneous denial for services billed because they used the ICD-10-PCS codes listed above, per the instructions in the previously mentioned provider manual section, may resubmit claims with applicable ICD-10-PCS codes. Providers are responsible for submitting claims with accurate and appropriate ICD-10-PCS codes. Medi-Cal’s timeliness guidelines for resubmissions, as described in the CIF Submission and Timeliness Instructions section of the Provider Manual, will be observed.

Provider Manual(s) Page(s) Updated
Inpatient ob rev drg (3, 5, 8–11)

6. 2021 HPE Income Eligibility Guidelines

The Hospital Presumptive Eligibility (HPE) program income eligibility guidelines have been updated for 2021, and are now available for download on the Hospital Presumptive Eligibility (HPE) Program page of the Medi-Cal website under the “HPE Program Provider Forms and Documents” heading. HPE providers must use the new 2021 HPE income eligibility guidelines when determining program eligibility. HPE providers should discard all previous eligibility guidelines for HPE. The table is updated annually.

7. TAR Required for Laparoscopy Billing

Effective retroactively for dates of service on or after October 1, 2017, CPT® code 58661 (laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), requires an approved Treatment Authorization Request (TAR) form for reimbursement under the Medi-Cal program.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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