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Medi-Cal Update

Local Educational Agency | 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. 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.

3. 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.

4. State Plan Amendment Updates: New LEA Practitioner Types, Services and Rates

Based on State Plan Amendment (SPA) 15-021, the Local Educational Agency (LEA) Medi-Cal Billing Option Program (BOP) is adding new procedure codes and modifiers associated with new services and practitioner types. In addition, LEA is updating reimbursement rates and modifying the rate reimbursement methodology for Targeted Case Management (TCM).

Removal of Service Limitations for Non-IEP/IFSP Students

The limit of 24 services per state fiscal year is discontinued for students whose care is not provided pursuant to an Individualized Education Plan (IEP) or Individualized Family Services Plan (IFSP). SPA 15-021 allows covered services to be provided to students as long as treatment services are pursuant to an Individualized Health Support Plan (IHSP) or other care plan, including but not limited to a 504 Plan, nursing plan or health services plan. Care plan requirements are detailed in the Part 2, LEA provider manual section, Local Educational Agency (LEA) Individualized Plans.

Allowable Services Expanded

The following chart details the newly reimbursable LEA services and their corresponding procedure codes. The chart indicates the locator keys of the Part 2, LEA provider manual sections where policy for the new services is located.

Short Description Procedure Code For Information See Provider Manual Section:
Group physical therapy and group occupational therapy treatment services CPT® code 97150 loc ed serv occu, loc ed serv phy
Nutritional counseling services HCPCS code S9470 loc ed serv nutri
Orientation and mobility assessment HCPCS code T1023 loc ed serv orient
Orientation and mobility treatment services CPT code 97533 loc ed serv orient
Respiratory therapy assessment CPT code 94618 loc ed serv respir
Respiratory therapy treatment services HCPCS code G0237 loc ed serv respir
School health aide services – Assistance with activities of daily living (ADLs) CPT code 97535 loc ed serv nurs

Qualified Rendering Practitioners Expanded

SPA 15-021 adds several new qualified rendering practitioners for LEA services. Practitioners who render the services should be identified on the claim with the following modifiers:

Practitioner Modifier Required on Claim
Associate marriage and family therapists HL
Licensed respiratory care practitioners None
Occupational therapy assistants CO
Orientation and mobility specialists None
Physical therapist assistants CQ
Physician assistants (PAs) U7
Registered associate clinical social workers HM
Registered dieticians AE
Speech-language pathology assistants HM

Provider Manual Updates

The LEA Provider Manual is updated with SPA-related policies. Three new LEA individual-services sections are added:

  • Local Educational Agency (LEA) Service: Nutrition

  • Local Education Agency (LEA) Service: Orientation and Mobility

  • Local Educational Agency (LEA) Service: Respiratory Care

Reimbursement and Billing

The Local Educational Agency (LEA) Billing Codes and Reimbursement Rates manual section includes the state fiscal year 2020 – 2021 maximum allowable interim reimbursement rates, procedure codes and required modifiers necessary to claim for the new SPA 15-021 services/practitioners. Providers should also refer to the provider manual section containing policy for each individual service (for example, nutrition) for details about service limitations, allowable units of service and authorization requirements.

Medi-Cal interim reimbursement rates are determined by applying the Federal Medical Assistance Percentage (FMAP) to the maximum allowable rate, or the rate billed by the LEA, whichever is less, per federal financial participation regulations. The current FMAP is 56.2 percent.

Retroactive Claim Submission

SPA 15-021 has an effective date of July 1, 2015; however, at this time the Department of Health Care Services (DHCS) instructs LEAs not to submit claims for services rendered prior to July 1, 2020. In a forthcoming Policy and Procedure Letter (PPL), DHCS will provide instructions for services rendered July 1, 2015 through June 30, 2020.

Current Claim Submission

As of the date of this publication, LEAs may begin submitting claims for the new SPA 15-021-related services and practitioner types for dates of service on or after July 1, 2020.

State Plan Amendment 16-001: Eligible TCM Population Expanded

Subsequent to the approval of SPA 15-021, DHCS received approval for SPA 16-001, which expands the population of students eligible to receive TCM services beyond those students with an IEP/IFSP. Under SPA 16-001, LEAs may receive reimbursement for general education students who have TCM services identified in an IHSP or other care plan. Additional information about the expanded student population is available in the Part 2, Local Educational Agency (LEA) Service: Targeted Case Management manual section.

TCM Certification

If an LEA intends to bill for TCM services through the LEA Program, DHCS will require a TCM certification form for Random Moment Time Survey (RMTS) participants (known as Time Survey Participants, or TSPs) that provide and bill for TCM services under the LEA Medi-Cal Billing Option Program.

The Local Educational Agency Medi-Cal Billing Option Program (LEA BOP) Targeted Case Management (TCM) Certification Statement (DHCS 9137) can be found on the DHCS website ( on the Local Educational Agency Medi-Cal Billing Option Program page. On the “Program Information” web page, providers should click “School Based Claiming Random Moment Time Survey” and then “TCM Certification Form.”

The TCM certification must be completed annually, and updated on a quarterly basis, as part of the RMTS process.

TCM Rates

Targeted Case Management services will be processed according to a new rate methodology. LEAs will no longer be reimbursed a low, medium or high rate for TCM claims. All TCM services will be reimbursed at the same rate for all qualified rendering practitioners, in 15-minute increments. TCM claims are billed using HCPCS code T1017.

TCM Qualified Practitioners

The following qualified practitioners are now eligible to bill for TCM services:

  • Registered credentialed school nurses (TD)

  • Licensed registered nurses (TD)

  • Certified public health nurses (TD)

  • Certified nurse practitioners (TD)

  • Licensed clinical social workers (AJ)

  • Credentialed school social workers (AJ)

  • Registered associate clinical social workers (HM)

  • Licensed psychologists (AH)

  • Licensed educational psychologists (AH)

  • Credentialed school psychologists (AH)

  • Licensed marriage and family therapists (no modifier)

  • Associate marriage and family therapists (HL)

  • Credentialed school counselors (no modifier)

  • Licensed vocational nurses (TE)

  • Program specialists (HO)

  • Licensed speech-language pathologists (GN) – New per SPA 16-001

  • Credentialed speech-language pathologists (GN) – New per SPA 16-001

  • Licensed occupational therapists (GO) – New per SPA 16-001

  • Licensed physical therapists (GP) – New per SPA 16-001

Physician Assistant Reimbursable Services

The following CPT procedure codes are reimbursable for Physician Assistants (PAs), as approved in SPA 15-021: 92551, 92552, 96150, 96151, 96156, 96158, 96159, 96164, 96165, 99173, 99401 and S9470. Policy related to billing by physician assistants is in the Part 2, Local Educational Agency (LEA) Service: Physician Billable Procedures manual section.

5. 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
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Vision Care
cal child sar (8, 9); genetic (10, 11)

6. Single-Use Drug/Biological Wastage Now Reimbursable with JW Modifier

Effective for dates of service on or after April 1, 2021, the HCPCS Level II, JW modifier may be used on drug claims to report the amount of drug or biological that is discarded and eligible for payment under the discarded drug policy.

The discarded drug amount is the amount of a single-use vial or other single-use package that remains after administering a dose/quantity of the drug to a Medi-Cal beneficiary. This policy applies to all separately billable drugs that are designated as single-use or single-dose on the FDA-approved label or package insert. Package size can be verified on the FDA website at

JW modifier should not be used for the following:

  • Drugs that are not separately payable, such as packaged Outpatient Prospective Payment System (OPPS) drugs or drugs administered in the Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) setting since they are not generally separately billable

  • Drugs paid under the Part B drug Competitive Acquisition Program (CAP) (the CAP remains on hold and there is currently no list of CAP medications)

  • Claims for hospital inpatient admissions that are billed under the Inpatient Prospective Payment System (IPPS)

  • When the actual dose administered is less than the HCPCS billing unit, since payment will not be made using fractional billing units and billing the discarded amount in addition to the HCPCS unit may result in overpayment

Instructions for billing and documentation:

  • Providers are to bill drug/biological wastage using the JW modifier in addition to documenting the name, dosage, route of administration and National Drug Code (NDC) of the drug/biological on the claim form

  • Providers are to document the discarded drug/biological in the Medi-Cal beneficiary’s medical records, including the date, time and quantity wasted

  • Providers are to bill the discarded drug/biological on a separate claim line with the JW modifier
Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Rehabilitation Clinics
modif (2–4); modif app (14)
Audiology and Hearing Aids
Durable Medical Equipment
Home Health Agencies/Home and Community-Based Services
Local Education Agency
Medical Transportation
Orthotics and Prosthetics
Vision Care
modif app (14)

7. 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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9. Provider Manual Revisions

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