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Medi-Cal Update

Obstetrics | September 2020 | Bulletin 555

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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. CPT Code for COVID-19 Testing Now a CLIA-Waived Test

Effective for dates of service on or after June 25, 2020, 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]) is now a Clinical Laboratory Improvement Amendments (CLIA)-waived test.

This code is intended for use as the industry standard for accurate reporting and tracking of antigen tests using immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by coronavirus disease 2019 (COVID-19). It is a Medi-Cal benefit.

3. 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 DHCSHospitalPE@dhcs.ca.gov.

4. 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.

5. 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
Clinics and Hospitals
General Medicine
Obstetrics
eval (3)
Medical Transportation cont ah (4)
Part 1 0c get start (4)

6. New Benefits to Aid Targeted Genomic Sequence Analysis

Effective for dates of service on or after October 1, 2020, CPT® code 81445 (targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5–50 genes) is now a once-in-a-lifetime Medi-Cal benefit that requires a valid Treatment Authorization Request (TAR).

CPT code 81455 (targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes) now has updated TAR requirements.

TAR requirements for both services now delineate between Somatic and Germline testing, and either Somatic or Germline testing may be approved if the test is approved by the U.S. Food and Drug Administration (FDA) as a Companion Diagnostic Device and the decision for additional treatment is contingent on the test results.

Provider Manual(s) Page(s) Updated
General Medicine
Obstetrics
Clinics and Hospitals
once (10); path molec (68–71); tar and non cd8 (11)
Inpatient Services tar and non cd8 (11)

7. Brachytherapy Codes C2616 and Q3001 are New Medi-Cal Benefits

Effective for dates of service on or after October 1, 2020, the policy for HCPCS codes C2616 (Brachytherapy source, non-stranded, yttrium-90, per source), and Q3001 (Radioelements for brachytherapy, any type, each) are new Medi-Cal benefits.

A Treatment Authorization Request is required for reimbursement.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
radi onc (4)

8. 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.

9. Modifier Update to HCPCS Codes G8431 and G8510 for Depression Screenings

Effective for dates of service on or after July 1, 2020, modifier HD, while not required, is an allowable modifier for HCPCs Level II codes G8431 (screening for depression is documented as positive, and a follow-up plan is documented) and G8510 (screening for depression is documented as negative, a follow-up plan is not required).

10. TAR Criteria Updated for CPT Code 81404

Effective for dates of service on or after October 1, 2020, coverage for CPT® code 81404 (molecular pathology procedure, Level 5) is limited to the listed services including VHL (von Hippel-Lindau tumor suppressor), full gene sequence. Reimbursement for a VHL test using code 81404 requires an approved Treatment Authorization Request (TAR) and documented clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (48)

11. Select Clinical Laboratory Rates Adjusted to 80 Percent of Medicare Rates

Effective retroactively for dates of service on or after April 1, 2019, rates for select clinical laboratory or laboratory services are adjusted to 80 percent of the lowest maximum allowance established by the federal Medicare program for the same or similar services in accordance with Welfare and Institutions Code (W&I Code), Section 14105.22. Providers may refer to the Medi-Cal Rates page on the Medi-Cal Provider website for the rates. No action is required of providers. An Erroneous Payment Correction (EPC) will be initiated to automatically correct reimbursement, as appropriate, for claims already submitted.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path organ (2, 3)

12. Providers May Bill for Remdesivir to Treat COVID-19

The U.S. Food and Drug Administration has issued an Emergency Use Authorization (EUA) for Remdesivir, an unapproved product, for the treatment of coronavirus disease 2019 (COVID-19).

In response to the EUA, effective for dates of service on or after July 15, 2020, the Department of Health Care Services (DHCS) is allowing providers to bill for Remdesivir under HCPCS code J3490 (unclassified drugs) until the Centers for Medicare and Medicaid Services (CMS) assign it a unique procedural code.

Providers, note the special billing instructions in the manual and the mandatory requirements for Remdesivir administration under EUA.

An approved Treatment Authorization Request (TAR) is required for reimbursement.

Manual sections reflecting changes will appear in a future bulletin.

13. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Effective Date Drug Summary of Changes    Page(s) Updated
April 1, 2020 PERTUZUMAB, TRASTUZUMAB and HYALURONIDASE-ZZXF Drug added, administration added, restriction added drugs cdl p1c (43)
April 1, 2020 TRASTUZUMAB-DTTB Drug added, administration added, restriction added drugs cdl p1d (37)
July 22, 2020 FOSTEMSAVIR Drug added, administration added, restriction added drugs cdl p1b (25)
September 1, 2020 PREGABALIN Drug added, administration added drugs cdl p1c (58)

Effective Date Drug Summary of Changes    Page(s) Updated
June 16, 2020 MITOMYCIN Restriction added, strength added drugs cdl p1b (74)
June 29, 2020 DOLUTEGRAVIR Administration added, strength added drugs cdl p1a (66)
September 1, 2020 CARBAMAZEPINE Administration added, strength added drugs cdl p1a (33)
September 1, 2020 ETHOSUXIMIDE Administration added, strength added drugs cdl p1b (13)
September 1, 2020 FLUCONAZOLE Restriction removed drugs cdl p1b (19)
September 1, 2020 LEVETIRACETAM Restriction removed, strength added drugs cdl p1b (55)
September 1, 2020 METFORMIN HYDROCHLORIDE Restriction removed, strength removed, strength added drugs cdl p1b (68)
September 1, 2020 TOPIRAMATE Strength added drugs cdl p1d (34)
September 1, 2020 ZONISAMIDE Strength added drugs cdl p1d (58)

14. Clinical Review: 2020 Standards of Care for Treatment of Type 2 Diabetes

A new DUR Educational Article titled “Clinical Review: 2020 Standards of Care for Treatment of Type 2 Diabetes” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

15. Pharmacy Fee-For-Service Coagulation Factor Reimbursement Changes

Pursuant to California's State Plan Amendment 19-0015, as approved by the Centers for Medicare & Medicaid Services (CMS) on January 20, 2019, the Department of Health Care Services (DHCS) has implemented a new fee-for-service reimbursement methodology for blood factors.

Effective for dates of services on or after July 1, 2020, providers billing for coagulation factors as defined in Welfare and Institution Code (W&I) 14105.86 shall bill and be reimbursed as outlined below.

  • Payment for clotting factor purchased through and dispensed by a federally recognized Hemophilia Treatment Center (HTC) or its contracted pharmacy will be the lower of:

    • The HTC’s actual acquisition cost for the drug as defined in Welfare and Institutions Code section 14105.46, plus a professional dispensing fee of $0.14 per unit, or

    • The Average Sales Price (ASP) as reported to the federal Centers for Medicare and Medicaid Services by the manufacturer pursuant to Section 1847A of the federal Social Security Act (42 U.S.C. §1395w-3a), plus 20%.
  • Payment for clotting factor purchased outside of a federally recognized HTC and dispensed by specialty pharmacies, Centers of Excellence, or any other provider will be the lower of:

    • The provider’s actual acquisition cost for the drug equal to invoice price minus any discounts (excluding a prompt pay discount of less than, or equal to 2%), rebates, or chargebacks, plus a professional dispensing fee of $0.04 per unit, or

    • The Average Sales Price (ASP) as reported to the federal Centers for Medicare and Medicaid Services by the manufacturer pursuant to Section 1847A of the federal Social Security Act (42 U.S.C. §1395w-3a) plus 20%.

This payment methodology is applicable to both pharmacy and non-pharmacy blood factor claims.

Additional information can be found in the Blood and Blood Derivatives Section of the Medi-Cal Provider Manual, specifically the Blood Factors: Billing for Bleeding and Clotting Disorders section.

Providers are encouraged to visit the Frequently Asked Questions specific to the implementation of the new fee-for-service reimbursement methodology for blood factors on the DHCS website.

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17. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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