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Medi-Cal Update

Inpatient Services | June 2022 | Bulletin 573

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1. Update: Second Booster Dose for Select COVID-19 Boosters Now a Benefit

Effective for dates of service (DOS) 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.

Providers may now submit claims for second booster dose administration using the following codes:

  • Pfizer:

    • Administration Code 0004A for the originally authorized formulation (phosphate buffered saline)

    • Administration Code 0054A is for the Tris buffered formulation

  • Moderna:

    • Administration Code 0064A

    • Administration Code 0094A for new booster formulation (50 mcg/0.5 ml)

Billing:

Providers can now bill for administration code 0094A. A booster dose of any manufacturer cannot be billed for the same recipient more than once on the same DOS.

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.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (41, 42, 44, 45); immun cd (5)

2. Updated: TAR Criteria for Inpatient Services

Effective for admissions on or after June 15, 2022, the Treatment Authorization Request (TAR) criteria for inpatient services has been updated.

Authorization shall be based upon medical necessity substantiated by the documents submitted with the TAR for each date of service requested.

TAR criteria for Acute Administrative Days (AAD)

Treatment Authorization Request (TAR) documentation requirements and criteria for fee-for-service AAD submitted with information regarding:

  • Type of AAD

  • Facility criteria

  • Eligible aid codes

Administrative Days are reimbursable for Medi-Cal recipients within the following types of aid codes:

  • Full scope aid codes and certain restricted aid codes with coverage for Long-Term Care (LTC) Services

  • Full scope aid codes and certain restricted aid codes with coverage for pregnancy-related services

  • Full scope aid codes and certain restricted aid codes with coverage for emergency services

AAD requires authorization with a TAR (18-1) or an eTAR, unless DHCS has waived the TAR requirement.

Acute Inpatient Intensive Rehabilitation (AIIR) Services

AIIR services require authorization with a Treatment Authorization Request (TAR) form 18-1 or an electronic TAR (eTAR), unless DHCS has waived the TAR requirement. A TAR for an AIIR admission is submitted by the facility providing AIIR services. The TAR should include the total number of acute inpatient intensive rehabilitation hospital days and be reflected in the Number of Days field (Box 17), as appropriate.

For those providers that require a TAR for AIIR services, refer to the TAR Criteria for Acute Inpatient Intensive Rehabilitation (AIIR) section in the Inpatient Services provider manual for AIIR document requirements and medical necessity criteria. For instructions on how to complete a TAR for AIIR services and additional information on, refer to the TAR Request for Extension of Stay in Hospital (Form 18-1) in the appropriate Part 2 manual.

3. Policy Clarification for Select Rapid Whole Genome Sequencing Codes

In the December 2021 article titled “Rapid Whole Genome Sequencing Codes are Covered Benefits Per AB 133”, Medi-Cal erroneously announced that codes 0094U, 0212U, 0213U and 81425 thru 81427 could not be used for the purpose of inpatient billing. To clarify, these codes cannot be used for outpatient billing. Current policy for the aforementioned rWGS codes is as follows:

Effective for dates of service on or after January 1, 2022, per Assembly Bill (AB) 133. Rapid Whole Genome Sequencing (rWGS) CPT® codes 0094U, 0212U, 0213U and 81425 thru 81427 are a covered benefit for any Medi-Cal beneficiary who is one year of age or younger and is receiving inpatient hospital services in an intensive care unit. These codes cannot be used for the purpose of outpatient billing. For inpatient billing, refer to Diagnosis Related Group Hospital Inpatient Payment Methodology.

CPT Code Description
0094U Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis
0212U Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband
0213U Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent, sibling)
81425 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis
81426 Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings)
81427 Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome)

4. American Rescue Plan Act Postpartum Care Extension Program Has Replaced the PPCE

The Provisional Postpartum Care Extension (PPCE) program was suspended on March 31, 2022. The information originally published on July 31, 2020 in the Medi-Cal update titled “Provisional Postpartum Care Extension” has been retired.

The legislature has implemented the American Rescue Plan Act (ARPA) Postpartum Care Extension (PCE) as an alternative program. For more information regarding the ARPA PCE, please visit the Pregnancy webpage on the Medi-Cal Provider website.

For information about other pregnancy-related services, providers may refer to the Pregnancy: Early Care and Diagnostic Services and the Pregnancy: Postpartum and Newborn Referral Services sections of the appropriate Part 2 Provider Manual.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
non spec mental (16); preg early (2); preg post (4)
Home Health Agencies/Home
and Community-Based Services
Inpatient Services
preg post (4)
Obstetrics preg early (2); preg post (4)

5. National Correct Coding Initiative Quarterly Update for July 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 July 1, 2022.

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

6. July 2022 Medi-Cal Provider “Coffee Break” Event

Medi-Cal's Outreach and Education department, along with the Department of Health Care Services is offering a “Coffee Break” event in July for category specific topics.

Topics discussed will include the following:

Topic Date
Remittance Advice Details July 5 and July 19
Medi-Cal Resources July 5 and July 19
Claims Follow-up July 6 and July 20
Eligibility/Share of Cost (SOC) July 6 and July 20
Lab Services July 7 and July 21
Home Health/Early and Periodic Screening Diagnostic and Treatment (EPSDT) July 7 and July 21
Medical Transportation July 12 and July 26
Durable Medical Equipment and Medical Supplies (DME) July 12 and July 26
Inpatient Obstetrics (OB) July 13 and July 27
Family Planning, Access, Care and Treatment (Family PACT) July 13 and July 27
California Children's Services (CCS)/Genetically Handicapped Person's Program (GHPP) July 14 and July 28
Obstetrics (OB)/Comprehensive Perinatal Services Program (CPSP) July 14 and July 28

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.

7. August 2022 Medi-Cal Provider Training Webinars

Outreach and Education (O&E) along with the Department of Health Care Services (DHCS) are offering category specific webinar sessions in August.

Session Date
Medi-Cal Resources 101 August 2
Navigating the Medi-Cal Website and Online Billing August 2 and 9
Long Term Care August 4
Inpatient and Outpatient Services August 9
Claims Follow-Up August 11
Health Access Programs August 16, 18 and 23
Hospital Presumptive Eligibility August 16
Every Woman Counts August 23
Durable Medical Equipment & Medical Supplies August 25
Medical Transportation Service August 25
Home Health Services August 30

A variety of courses will be offered in each of the categories listed. Providers must register through the Medi-Cal Learning Portal (MLP) Event Calendar.

Providers will be able to print class materials and ask questions during the training sessions.

To view the webinars, providers must have internet access and a user profile in the MLP. Detailed instructions about the registration process and how to access webinar classes are available on the Outreach & Education page of the Medi-Cal Providers website.

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

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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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