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Medi-Cal Update

Obstetrics | December 2020 | Bulletin 558

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1. New COVID-19 Testing Codes are Medi-Cal Benefits

Effective for dates of service on or after October 6, 2020, the following CPT® codes have been established for reporting medical services sparked by the public health response to the coronavirus disease 2019 (COVID-19) pandemic.

CPT Code Description
87636 Infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

Two of the newly approved codes, 87636 and 87637, allow a single test to simultaneously detect the novel coronavirus, and a combination of common viral infectious agents, including influenza A/B and respiratory syncytial virus.

The new category I CPT code, 87811, can be used to report infectious agent antigen detection by immunoassay with direct visual observation.

All three codes do not have any gender or age restrictions, have a frequency limit of one of each per day, any provider, per patient, and may be billed with any valid ICD-10-CM codes.

The codes above are exempt from the 10 percent payment reductions in the Welfare and Institutions (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 implemented to reprocess affected claims.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path micro (11); presum bill (7, 8)
Pharmacy presum bill (7, 8)

2. 2021 CPT® Annual Update

The 2021 Quarter 1 updates to the Current Procedural Terminology (CPT) codes are available in the December 2020 CPT Policy Updates PDF. Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for the dates of service on or after January 1, 2021. Please refer to the 2021 CPT code book for complete code descriptions.

The 2021 Quarter 1 updates to the Healthcare Common Procedure Coding System (HCPCS) Level II codes are also effective for Medicare on January 1, 2021. However, due to a delay caused by the coronavirus disease 2019 (COVID-19), Medi-Cal is not able to adopt the updates in time to publish the associated policy in the January Medi-Cal Update.

Providers should not use the 2021 Quarter 1 HCPCS Level II codes to bill for Medi-Cal or Presumptive Eligibility for Pregnant Women (PE4PW) services until notified to do so in a future Medi-Cal Update.

Provider Manual(s) Page(s) Updated
AIDS Waiver Program modif app (10, 11)
Audiology and Hearing Aids audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11)
Chronic Dialysis Clinics cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12)
Clinics and Hospitals
General Medicine
cal child ser (1, 25, 34, 36, 37, 50, 56); cardio (3); eval (2, 4–7, 9, 13, 14, 27, 29); ev woman (24, 31, 32); fam planning (6, 9, 10, 12); hyst (3); immun (31); immun cd (1); medne neu (5); medne oto (1); medne pul (4); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9, 11, 25, 27); once (7); ophthal (2, 3, 12); path molec (9, 16, 17, 30, 43–47, 51, 52, 56, 60, 70, 93); preg determ (1); preg early (5); preg glo (4); preg per (2); preg post (6); presum bill (1, 2, 4, 9, 10, 11, 12, 16); prev (2, 3, 6, 8, 9); psych (4); radi (5); radi dia (3); radi onc (1); rates max (5); respir (4); spec (2); surg aud (5); surg bil mod (7, 8); surg cardio (3, 10); surg muscu (2); surg nerv (1); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Community Based Services audio (4)
Durable Medical Equipment cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); respir (4)
Home Health Agencies/Home and Community-Based Services cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); preg post (6)
Inpatient Services cal child ser (1, 25, 34, 36, 37, 50, 56); hyst (3); preg post (6); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Local Education Agency
Medical Transportation
Orthotics and Prosthetics
cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11)
Obstetrics cal child ser (1, 25, 34, 36, 37, 50, 56); eval (2, 4–6, 8, 12, 13, 26, 28); ev woman (24, 31, 32); fam planning (6, 9, 10, 12); hyst (3); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9, 11, 25, 27); once (7); path molec (9, 16, 17, 30, 43–47, 51, 52, 56, 60, 70, 93); preg determ (1); preg early (5); preg glo (4); preg per (2); preg post (6); presum bill (1, 2, 4, 9, 10, 11, 12, 16); radi (5); radi dia (3); radi onc (1); rates max (5); surg bil mod (7, 8); tar and non cd1 (8, 21–23); tar and non cd2 (32, 33); tar and non cd3 (13); tar and non cd5 (25, 28, 30, 33); tar and non cd6 (4, 9, 31); tar and non cd8 (3, 5, 7, 8, 10, 12, 13, 14); tar and non cd9 (4, 5, 6, 36)
Pharmacy cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); pharm serv (2–7, 10); presum bill (1, 2, 4, 9, 10, 11, 12, 16)
Psychological Services cal child ser (1, 25, 34, 36, 37, 50, 56); psychol (6); psychol cd (1); spec (2)
Rehabilitation Clinics audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); immun (31); immun cd (1); modif app (10, 11); modif used (3, 4, 6–8, 10, 12); non ph (9,11, 25, 27); respir (4)
Therapies audio (4); cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); respir (4)
Vision Care cal child ser (1, 25, 34, 36, 37, 50, 56); modif app (10, 11); pro serv (3, 9, 11, 12, 19); rates max optom (2–4)

3. Medi-Cal Lengthens Transition Time to Full Implementation – Go-Live on April 1, 2021

Given the ongoing challenges and constantly evolving health care landscape associated with the unprecedented coronavirus disease 2019 (COVID-19) public health emergency (PHE), the Department of Health Care Services (DHCS), in partnership and collaboration with Magellan Medicaid Administration, Inc. (Magellan), has decided to lengthen the time for the full implementation of the transition to Medi-Cal Rx by three  months. DHCS and Magellan will continue to dedicate their combined efforts and rigorous preparations towards Assumption of Operations (AOO) for Medi-Cal Rx on April 1, 2021. In the interim, all current processes and protocols, both effectuated by DHCS and our Medi-Cal managed care plans (MCPs), respectively, will remain unchanged and in place until Medi-Cal Rx launches.

While neither DHCS nor Magellan takes this decision lightly, we are confident that given the COVID-19 PHE, this decision is in the best interests of our Medi-Cal beneficiaries and providers. Lengthening the time for full implementation will help to ensure a more complete transition, as well as mitigate impacts to beneficiaries in accessing their medication. Moving the launch of Medi-Cal Rx to April 1, 2021, will provide additional and valuable opportunities for Medi-Cal providers, beneficiaries, MCPs, and other interested parties to become better acclimated to, and familiar with new Medi-Cal Rx policies and processes, through additional messaging from DHCS and Magellan, additional targeted stakeholder engagement and outreach efforts and additional provider trainings.

Please note that DHCS will be working to update applicable provider guidance and associated Medi-Cal Rx provider bulletins/Newsflash articles in the coming weeks to reflect the April 1, 2021, go-live date. With the exception of the three-month shift in the go-live date, all other aspects of the transition communicated to our providers via bulletins through the Medi-Cal and Medi-Cal Rx websites remain unchanged.

DHCS appreciates your continued support and collaboration relative to this important project and looks forward to the successful launch and AOO of Medi-Cal Rx on April 1, 2021. If you have any questions about this notification, please feel free to direct them to the Medi-Cal Rx Project Team at RxCarveOut@dhcs.ca.gov.

4. Psychiatric Collaborative Care Management is a New Benefit

Effective for dates of service on or after January 1, 2021, CPT codes 99492 (initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional), 99493 (subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional) and 99494 (initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional) are new Medi-Cal benefits.

Frequency limits for CPPT codes 99492 and 99493 are once per calendar month. The frequency limit for code 99494 is twice per calendar month. CPT code 99492 and 99493 may not be reimbursed within the same calendar month.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics modif used (12)
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
eval (9, 29, 30); modif used (12); non ph (9); tar and non cd9 (36)
Rehabilitation modif used (12); non ph (9)

5. Skin Substitute Now a Medi-Cal Benefit

Effective for dates of service on or after December 1, 2020, HCPCS code Q4151 (AmnioBand or Guardian, per square centimeter) is a Medi-Cal benefit.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
surg integ (4); non ph (12, 34); modif used (14)
Obstetrics
Rehabilitation Clinics
non ph (12, 34); modif used (14)
Chronic Dialysis Clinics modif used (14)

6. Medicare Denial Requirement Eliminated for Certain Abortion CPT® Codes

Effective for dates of service on or after January 1, 2021, the following CPT codes, 59840, 59841, 59850 through 59852 and 59855 through 59857 are eliminated as a requirement for Medicare denial when billing for certain abortion services.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
abort (1)

7. Resetting PIN Through Telephone Service Center

Active Medi-Cal fee-for-service providers with seven-character Provider Identification Numbers (PINs) may now request a Telephone Service Center (TSC) agent to reset their PIN.

The PIN is the additional validation of an enrolled provider’s identity that is used when a provider conducts business transactions with the Medi-Cal program and the Fiscal Intermediary (FI). Some examples of transactions requiring use of the PIN include recipient eligibility verification and accessing the Transactions area of the Medi-Cal website.

Callers qualify to have their PIN reset only after caller validation protocols are completed.

Once the caller is validated, the TSC agent can reset the PIN and release the PIN over the telephone. Providers do not need to wait for notification through the mail. TSC agents who cannot validate the required information cannot reset the PIN.

If the information is not adequate, the provider may have another qualified person in their office reattempt the PIN reset or they may request a PIN reset using the existing paper process. Providers may refer to “How to Obtain Enrollment and Medi-Cal Supplemental Changes Forms” in the Part 1, Provider Guidelines, provider manual section for more information.

Due to certain provider requirements, PIN resets through TSC are not allowable for select providers, including, but not limited to, dental and mental health providers. PIN resets are real-time and immediate; however, it will take up to two hours before data files will be available (for example, the PDF RAD and HIPAA eligibility files). An informational message will be displayed on the Medi-Cal website to inform providers that data files are not available until the PIN re-encryption process is completed.

Information about PIN resets has been added to the PDF RAD Web Portal User Guide. Additionally, information about PINs has been streamlined under the “Contacting Medi-Cal” heading on the FAQs page of the Medi-Cal website.

8. Amended TAR Criteria for MLH1 Gene Analysis

Effective for dates of service on or after January 1, 2021, Treatment Authorization Request (TAR) criteria is amended for CPT code 81288 (MLH1 [mutL homolog 1, colon cancer, nonpolyposis type 2] [eg, hereditary non-polyposis colorectal cancer, Lynch syndrome] gene analysis; promoter methylation analysis). The TAR must now document the following:

  • Patient with cancer(s) associated with Lynch Syndrome, and

  • The tumor demonstrates microsatellite instability or immunohistochemistry results indicating loss of MLH1 protein expression
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (32)

9. National Correct Coding Initiative Quarterly Update for January 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 January 1, 2021.

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

10. January Through February 2021 Medi-Cal Provider Training Webinars

Beginning January 5, 2021 and continuing throughout the month of February, Medi-Cal providers may participate in provider training webinars that are:

  • Held twice a day on Tuesdays and Thursdays at 10:00 a.m. and 2:00 p.m.

  • Hosted in real-time by a Medi-Cal Regional Representative

  • Designed to cover basic, advanced and specialty billing topics

Registration for the training webinars is available on the Medi-Cal Learning Portal (MLP) or the Medi-Cal home page.

Providers will be able to print class materials and ask questions during the live webinar training sessions. The MLP offers training courses that can be viewed according to your schedule if you are unable to attend one of the live webinars.

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

11. 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
October 1, 2020 BELANTAMAB MAFODOTIN-BLMF Drug added, administration added, restriction added drugs cdl p1a (33)
October 1, 2020 BLINATUMOMAB Drug added, administration added, restriction added drugs cdl p1a (38)
October 1, 2020 CARFILZOMIB Drug added, administration added, restriction added drugs cdl p1a (51)
October 1, 2020 RIPRETINIB Drug added, administration added, restriction added drugs cdl p1c (74)
October 1, 2020 TALIMOGENE LAHERPAREPVEC Drug added, administration added, restriction added drugs cdl p1d (17)
December 1, 2020 CHLORDIAZEPOXIDE HCL Drug added, administration added, restriction added drugs cdl p1a (58)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2020 METHOTREXATE Restriction changed drugs cdl p1b (103)
October 1, 2020 PANITUMUMAB Restriction changed drugs cdl p1c (32)
December 1, 2020 ACYCLOVIR Restriction removed drugs cdl p1a (5)
December 1, 2020 CLONAZEPAM Restriction changed drugs cdl p1a (68)
December 1, 2020 DIAZEPAM Restriction removed, restriction radded drugs cdl p1a (62)
December 1, 2020 FLURAZEPAM Restriction added drugs cdl p1b (33)
December 1, 2020 LATANOPROST Restriction removed drugs cdl p1b (78)
December 1, 2020 LORAZEPAM Restriction changed drugs cdl p1b (91)
December 1, 2020 RAMELTEON Restriction changed drugs cdl p1c (68)
December 1, 2020 TEMAZEPAM Restriction added drugs cdl p1d (19)
December 1, 2020 TRIAZOLAM Restriction added drugs cdl p1d (40)
December 1, 2020 VALACYCLOVIR HCL Restriction removed drugs cdl p1d (45)
December 1, 2020 ZOLPIDEM TARTRATE Restriction added drugs cdl p1d (56)

12. 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.

13. Provider Manual Revisions



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