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Medi-Cal Update

Obstetrics | November 2020 | Bulletin 557

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1. Reimbursement Rates are Updated for COVID-19 Testing

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) have updated reimbursement rates.

Additionally, the Department of Health Care Services (DHCS) is establishing the reimbursement rates at 100 percent of the Medicare rate for 86408 and 86409. These codes are 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, these rates 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.

Updated rates are as follows:

Codes Description Medicare Rate
86408 Neutralizing antibody, (SARSCoV-2), screen $42.13
86409 Neutralizing antibody, (SARSCoV-2), titer $79.61

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

2. CPT Code 86413 Reimbursement Rate Update

Effective for dates of service on or after September 8, 2020, the Department of Health Care Services (DHCS) updated the reimbursement rate for CPT® code 86413 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] antibody, quantitative).

DHCS established the reimbursement rate at 100 percent of the Medicare rate for 86413. This code 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 (AB) 97 payment reduction.

An Erroneous Payment Correction (EPC) will be implemented to reprocess the affected claims.

The updated manual pages reflecting this change will be released in a future Medi-Cal Update.

3. New Provider Web Page and Checklist on the Medi-Cal Provider Website

The Department of Health Care Services (DHCS) encourages new providers to visit its New Provider web page. It was launched simultaneously with its new Medi-Cal Provider website earlier this year.

Medi-Cal’s New Provider web page offers an organized and central location for key information, guided steps, helpful documents and charts, as well as direct links to areas of the Medi-Cal Provider website that a new provider is encouraged to visit to help setup and have a successful future as a provider within the Medi-Cal program.

The New Provider web page is located in the Providers tab on the new Medi-Cal Provider website. The web page includes important information on the following subject matters:

  • Billing Basics

  • Checkwrite and Remittance Advice Details (RADs)

  • Claim Forms and Claim Timeliness (online and paper-based)

  • Eligibility and Share of Cost (SOC)

  • Links to Medi-Cal Learning Portal (MLP), Medi-Cal Subscription Service (MCSS) and Provider Enrollment

  • Provider Publications (including Frequently Asked Questions)

  • Provider Training (including Provider Training Seminar information)

  • Medi-Cal Key Contacts (Call Center, Regional Representatives and Small Provider Billing Unit)

  • Treatment Authorization Requests (TARs) and electronic TARs (eTARs)

In addition, DHCS has developed a New Provider Checklist whereby providers will find a step-by-step checklist for building knowledge and ensuring success as a new provider. Providers are also encouraged to view and utilize the Navigating Medi-Cal and Specialty Programs chart also located on the web page.

Furthermore, providers are encouraged to subscribe to the convenient and free Medi-Cal Subscription Service (MCSS) to receive the latest policy news and program updates that are most relevant to their provider communities and subject areas of interest. Additional information about the MCSS including Frequently Asked Questions (FAQs) can be found on the MCSS Help web page.

4. Reimbursement Rate Increase for Fetal Gene Analysis

Effective retroactively for dates of service on or after January 1, 2020, the Medi-Cal reimbursement rate for CPT®  code 81420 (fetal chromosomal aneuploidy [eg, trisomy 21, monosomy X] genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21) is increased to $607.24.

The Medi-Cal Rates web page has been updated.

An Erroneous Payment Correction (EPC) will be implemented to reprocess the affected claims.

5. Cinacalcet Tablets Now a Medi-Cal Benefit

Effective retroactively for dates of service on or after September 1, 2019, HCPCS code J0604 (cinacalcet, oral, 1 mg, [for ESRD on dialysis]) is a Medi-Cal benefit.

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

Providers will need to rebill denied claims for medications that were dispensed to beneficiaries from September 1, 2019, to November 23, 2020. The timeliness requirement for the rebilling of denied claims will be waived. End Stage Renal Disease (ESRD) facilities must submit claims with AX modifier for reimbursement using the Traditional Drug Add-On Payment Adjustment.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
non inject (17, 18)

6. Changes to National Correct Coding Initiative October 2020 Quarterly Update

The Centers for Medicare & Medicaid Services (CMS) issued replacement files with revised procedure-to-procedure (PTP) files for the 4th quarter of 2020. The mandatory national edits were incorporated into the Medi-Cal claims processing system and were effective for dates of service on or after October 1, 2020.

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

For more information on NCCI and this latest update, see the National Correct Coding Initiative page on the Medicaid website.

7. Pilot Program for End Stage Renal Disease Extended Through December 31, 2021

Effective for dates of service on or after January 1, 2021, the End Stage Renal Disease Pilot Program is extended through December 31, 2021 for VillageHealth, carrier code S323.

Note: All existing billing instructions remain the same.
Provider Manual(s) Page(s) Updated
Part 1 mcp spec (7)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
dial end (6); oth hlth (1)
Allied Health
Inpatient Services
Long Term Care
Obstetrics
Outpatient Services
Pharmacy
Vision Care
oth hlth (1)

8. 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, changed or deleted 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
September 14, 2020 Pralsetinib Drug added, administration added drugs cdl p1c (54)
drugs cdl p4 (11)
November 1, 2020 Baloxavir Marboxil Drug added, administration added drugs cdl p1a (21)
drugs cdl p4 (7)
November 1, 2020 Cyproheptadine Drug added, administration added drugs cdl p1a (52)
drugs cdl p4 (13)
November 1, 2020 Mupirocin Drug added, administration added drugs cdl p1b (115)
drugs cdl p4 (5, 28)
November 1, 2020 Segesterone Acetate and Ethinyl Estradiol Drug added, administration added, restriction added drugs cdl p1d (3)
drugs cdl p4 (22)
November 1, 2020 Ubrogepant Drug added, administration added, restriction added drugs cdl p1d (44)
drugs cdl p4 (14)
Effective Date Drug Summary of Changes Page(s) Updated
November 1, 2020 Aspirin Dosage added, strength added drugs cdl p2 (3)
November 1, 2020 Cefdinir Restriction removed drugs cdl p1a (36)
November 1, 2020 Divalproex Sodium Restriction removed drugs cdl p1a (66)
November 1, 2020 Meloxicam Restriction removed, note removed drugs cdl p1b (96)
November 1, 2020 Nabumetone Restriction removed, note removed drugs cdl p1c (1)
November 1, 2020 Naproxen Restriction removed, note removed drugs cdl p1c (4)
November 1, 2020 Ondansetron Dosage added, strength added drugs cdl p1c (26)
November 1, 2020 Piroxicam Restriction removed, note removed drugs cdl p1c (49)
November 1, 2020 Salsalate Restriction removed drugs cdl p1d (1)
November 1, 2020 Sulindac Restriction removed, note removed drugs cdl p1d (15)
November 1, 2020 Tolmetin Restriction removed, note removed drugs cdl p1d (33)
December 1, 2020 Ezetimibe Restriction removed drugs cdl p1b (23)
December 1, 2020 Solifenacin Succinate Restriction removed drugs cdl p1d (9)

9. Drug Safety Communication: Stronger Warning Labels for Benzodiazepines

A new DUR Educational Article titled “Drug Safety Communication: Stronger Warning Labels for Benzodiazepines (PDF)” is available on the DUR: Educational Articles page of the Medi-Cal website.

10. Get the Latest Medi-Cal News: Subscribe to MCSS Today

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

  2. Enter your email address and ZIP code and select a subscriber type

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

11. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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