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Medi-Cal Update

Medical Transportation | September 2020 | Bulletin 540

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1. CPT Code for COVID-19 Testing Exempt from AB 97 10 Percent Payment Reduction

Effective for dates of service on or after June 25, 2020, the American Medical Association created CPT® code 87426 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)]) for reporting antigen testing of patients suspected of being infected with the coronavirus disease 2019 (COVID-19).

Additionally, the Department of Health Care Services (DHCS) is establishing the reimbursement rate at 100 percent of the Medicare rate for the new code. It is exempt from the ten percent payment reductions in Welfare and Institutions Code (W&I Code) Section 14105.192.

Upon expiration of the public health emergency or national emergency, this rate will be amended to correspond with the clinical laboratory services methodology in W&I Code Section 14105.22, including the application of the Assembly Bill 97 (AB 97) payment reduction.

An erroneous payment correction (EPC) will be implemented to reprocess the affected claims.

2. New Policy Changes to the Hospital Presumptive Eligibility Program

As California continues to respond to coronavirus disease 2019 (COVID-19), the Hospital Presumptive Eligibility (HPE) Program will temporarily expand presumptive eligibility (PE) coverage to a new coverage group of individuals who are 65 or older and whose income is below 138 percent of the Federal Poverty level (FPL), effective immediately. This new coverage group is referred to as the “Aged” HPE group. This coverage group is allowed two (2) periods of PE in a twelve-month period and will be assigned aid code 7D. This expansion will be in effect through the end of the COVID-19 public health emergency.

DHCS is also expanding presumptive eligibility periods through HPE for adults that are age 19 years and over. HPE will now provide two (2) periods of presumptive eligibility in a twelve-month period for adults age 19 and over. This change is effective immediately and will be in effect through the end of the COVID-19 public health emergency.

DHCS has received federal approval on these new policy changes through California State Plan Amendment 20-0024.

It is critical that HPE Providers monitor the Hospital PE Program Medi-Cal website for future articles and materials scheduled to publish during May and June 2020.

Questions concerning the HPE expansion should be sent to

3. CPT Codes 86408 and 86409 for COVID-19 Testing are Medi-Cal Benefits

Effective for dates of service on or after August 10, 2020, CPT® codes 86408 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; screen) and 86409 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; titer) for coronavirus disease 2019 (COVID-19) are now Medi-Cal benefits. Codes 86408 and 86409 do not have any gender or age restrictions; have a frequency limit of one per day, any provider, per patient; and may be billed with any ICD-10-CM codes.

4. Introducing the RAD Repository

Providers now have access to Remittance Advice Details (RAD) codes and messages in one central location: the RAD Repository.

The RAD Repository is a one-stop shop for information about remittance details, billing tips and code descriptions. Previously, RAD codes and messages were presented in separate documents. The new RAD Repository pulls all of the documents into one spreadsheet that streamlines claims billing data for providers.

The new RAD Repository will help providers find pertinent billing information more quickly. In addition, users with cognitive, visual or hearing disabilities will have an enhanced experience as the spreadsheet complies with Americans with Disabilities Act (ADA) standards.

Provider Manual(s) Page(s) Updated
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5. New Medi-Cal Provider Website: Provider Survey and Feedback

The Department of Health Care Services (DHCS) invites all Medi-Cal providers, stakeholders and interested parties to participate in a brief Medi-Cal Provider website survey after visiting the new Medi-Cal Provider website. Survey results will provide valuable information to DHCS for future website improvements.

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