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Medi-Cal Update

Obstetrics | February 2021 | Bulletin 560

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1. Reimbursement of COVID-19 Vaccine and Monoclonal Antibody Administration for Medical Providers

This article is regarding the administration and reimbursement of COVID-19 vaccines and monoclonal antibodies when administered by medical providers as a Physician Administered Drug (PAD). This is one in a series of articles containing the Department of Health Care Services’ (DHCS) instructions for billing and reimbursement as they pertain to COVID-19 therapeutics.

The U.S. Food and Drug Administration (FDA) issued Emergency Use Authorizations (EUAs) for two investigational monoclonal antibody therapies. The first was bamlanivimab on November 9, 2020, followed by casirivimab and imdevimab on November 21, 2020. Both products are for the treatment of mild-to moderate COVID-19 in adult and pediatric patients (12 years of age and older weighing at least 40 kg) with positive COVID-19 test results who are at high risk for progressing to severe COVID-19 and/or hospitalization. Both products may only be administered in settings in which health care providers have immediate access to medications to treat a severe infusion reaction, such as anaphylaxis, and the ability to activate the emergency medical system (EMS), as necessary. Review the Fact Sheet for Healthcare Providers for bamlanivimab EUA and the Health Care Provider Fact Sheet for casirivimab and imdevimab EUA regarding the limitations of authorized use and mandatory requirements.

DHCS will reimburse for the administration (infusion) of these monoclonal antibodies when administered in accordance with the respective EUAs.

Since the vaccines and monoclonal antibodies are currently supplied by the federal government free to providers, DHCS will only reimburse the administration fees for both the vaccines and monoclonal antibodies. These reimbursements will be at the Medicare rate approved by Centers for Medicare & Medicaid Services (CMS). DHCS will provide future guidance regarding the billing and reimbursement of provider purchased products at the appropriate time.

Providers must bill for administration of the COVID-19 vaccines and monoclonal antibodies using the appropriate administration codes for reimbursement.

Billing Instructions for the COVID-19 Vaccines

Providers must submit the appropriate vaccine administration codes for billing the first and second doses of the Pfizer-BioNTech and Moderna vaccines as applicable.

  • 0001A ( Pfizer-Biontech COVID-19 Vaccine Administration – First Dose)

  • 0002A (Pfizer-Biontech COVID-19 Vaccine Administration – Second Dose)

  • 0011A (Moderna COVID-19 Vaccine Administration – First Dose)

  • 0012A (Moderna COVID-19 Vaccine Administration – Second Dose)

Providers must administer the vaccine in accordance with the CDC and Advisory Committee on Immunization Practices (ACIP) requirements.

Providers must meet the storage and recordkeeping requirements, including recording the administration of the vaccine to patients in their own systems within 24 hours and to the California Immunization Registry (CAIR2) within 72 hours. They must verify through CAIR2 that the vaccine for the second dose is the same brand that was administered for the first dose.

It is important to provide vaccine recipients emergency use authorization fact sheet for patients/caregivers and vaccination cards identifying the brand of vaccine administered and the date of their second vaccination (if applicable).

Providers should not use the following CPT® codes when billing for these vaccines, as they are currently not reimbursed by DHCS:

  • 91300 (severe acute respiratory syndrome coronavirus 2 (SARSs-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3ml dosage, diluent reconstituted, for intramuscular use)

  • 91301 (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5ml dosage, for intramuscular use)

Billing Instructions for the Monoclonal Antibodies

DHCS will reimburse for the cost of administration (infusion) when billed with the following administration codes as appropriate when administered in accordance with FDA EUAs.:

  • M0239 (Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring) – effective date 11/9/2020

  • M0243 (Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring) – effective date 11/21/2020

Providers should not use the following HCPCS codes when billing for these monoclonal antibodies, as they are currently not reimbursed by DHCS:

  • Q0239 (injection, bamlanivimab-xxxx, 700 mg)

  • Q0243 (injection, casirivimab and imdevimab, 2,400 mg)
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (5–22); immun cd (3, 4); modif used (5, 6); non ph (12, 15, 27, 30)
Chronic Dialysis Clinics immun (5–22); immun cd (3, 4); modif used (5, 6)
Pharmacy immun (5–22); immun cd (3, 4); modif used (5, 6)

2. Update to Billing Policy for Infectious Agent Antigen Detection

Effective for dates of service on or after January 1, 2021, CPT® code 87426 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)]) may now be reported in conjunction with any of the following codes:

HCPCS/CPT Code Description
87635 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
U0002 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC
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
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

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 (9)

3. 2021 HCPCS Annual Update

The 2021 Quarter 1 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the HCPCS Policy Updates PDF. Only those codes representing current and past Medi-Cal and Family Planning, Access, Care and Treatment (FPACT) benefits are included in the list of updates.

Split-bill policy for select CPT® codes will be provided in a future Medi-Cal Update.

The code additions, changes and deletions are effective for dates of service on or after January 1, 2021. Please refer to the HCPCS Level I and II code books for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinic immun cd (1); inject cd list (2–6, 8, 11, 12, 15, 18, 20, 21, 24); inject drug a-d (3, 4, 29, 30, 39, 40); inject drug i-m (7, 11–13); inject drug n-r (21, 22); inject drug s-z (25–29); modif used (1, 12–15); non inject (18–21)
Clinics and Hospitals
General Medicine
chemo drug a-d (12, 13, 32); chemo drug e-o (24–26, 31); chemo drug p-z (11, 12, 25–28); immun cd (1); inject cd list (2–6, 8, 11, 12, 15, 18, 20, 21, 24); inject drug a-d (3, 4, 29, 30, 39, 40); inject drug i-m (7, 11–13); inject drug n-r (21, 22); inject drug s-z (23–26); modif used (1, 12–15); non inject (18–21); non ph (10, 13–16, 27); once (1); prev (9); radi dia (3, 20–22, 24); radi nuc (7)
Family PACT ben fam (3, 6, 9, 10, 32); office (1, 2, 4, 5, 7–10); pharm (3)
Home Health Agencies/Home and Community-Based Services home hlth (3); home hlth cd (1, 2)
Obstetrics immun cd (1); inject cd list (2–6, 8, 11, 12, 15, 18, 20, 21, 24); inject drug a-d (3, 4, 29, 30, 39, 40); inject drug i-m (7, 11–13); inject drug n-r (21, 22); inject drug s-z (25–29); modif used (1, 12–15); non inject (18–21); non ph (10,13–16, 27); once (1); radi dia (3, 20–22, 24); radi nuc (7)
Pharmacy immun cd (1); inject cd list (2–6, 8, 11, 12, 15, 18, 20, 21, 24); inject drug a-d (3, 4, 29, 30, 39, 40); inject drug i-m (7, 11–13); inject drug n-r (21, 22); inject drug s-z (25–29)
Rehabilitation Clinics immun cd (1); inject cd list (2–6, 8, 11, 12, 15, 18, 20, 21, 24); inject drug a-d (3, 4, 29, 30, 39, 40); inject drug i-m (7, 11–13); inject drug n-r (21, 22); inject drug s-z (25–29); modif used (1, 12–15); non inject (18–21); non ph (10, 13–16, 27)

4. Proprietary Laboratory Analyses (PLA) Codes Implementation Complete

Effective for dates of service on or after January 1, 2021, providers may submit claims to Medi-Cal for services defined by Proprietary Laboratory Analyses (PLA) codes. These codes include a range of laboratory tests including, but not limited to multianalyte assays with algorithmic analyses (MAAA) and genomic sequencing procedures (GSP). MAAAs are procedures that utilize multiple results derived from assays of various types, including molecular pathology assays, fluorescent in situ hybridization assays and non-nucleic acid-based assays (e.g., proteins, polypeptides, lipids, carbohydrates). Consistent with CPT® coding guidelines, when a PLA code is available, the specific PLA code takes precedence.

Providers can reference the new manual section: Proprietary Laboratory Analyses (PLA) (prop lab) for active codes and additional billing instructions. The TAR and Non-Benefit List: Codes 0001M thru 0999U (tar and non cd0) lists out all the PLA codes requiring a Treatment Authorization Request (TAR) or those in deny status.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
presum bill (1, 18, 19); prev (10); prop lab (1–58); tar and non cd0 (1–32)

5. Temporary Billing Policy for Contraceptive Patches

Effective for dates of service on or after January 1, 2021, until further notice, providers billing for Twirla (levonorgestrel and ethinyl estradiol transdermal system) or Xulane (norelgestromin and ethinyl estradiol transdermal system) using HCPCS code J7304 (contraceptive supply, hormone containing patch, each), must submit a purchase invoice along with the product National Drug Code (NDC) to ensure appropriate reimbursement.

This temporary billing policy became necessary due to recent availability of Twirla, which, like Xulane, can be billed using J7304. Policy will be established to delineate the billing of both products using modifiers, which will be released in a future Medi-Cal and Family PACT Update, with new billing instructions for providers.

6. Updated Policy for Tobacco Cessation Counseling Codes

Effective for dates of service on or after March 1, 2021, policy for CPT® codes 99406 (smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 99407 (smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) has been updated. Frequency limitation has been adjusted to allow for one counseling session per day, with no yearly frequency limit. In addition, allowable modifiers have been adjusted to include SA, SB, U7, U9, 24 and 99. Place of Service (POS) restrictions have also been removed to allow reimbursement in all settings, including, but not limited to inpatient, outpatient and emergency department.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics modif used (3)
Clinics and Hospitals
General Medicine
Obstetrics
eval (10, 35); modif used (3); non ph (9, 25)
Rehabilitation Clinics modif used (3); non ph (9, 25)

7. Ferumoxytol Approved Policy Update for Iron Deficiency Anemia in Adults

Effective retroactively for dates of service on or after February 5, 2018, indications for HCPCS codes Q0138 (injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg [non-ESRD use]) and Q0139 (injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg [for ESRD on dialysis]) are updated. Ferumoxytol (Feraheme) is approved for all eligible adult patients with iron deficiency anemia, with or without chronic kidney disease.

Affected claims will be reprocessed via an Erroneous Payment Correction (EPC).

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject drug e-h (37, 38); modif used (13)
Clinics and Hospitals
General Medicine
Obstetrics
inject drug e-h (37, 38); modif used (13); non ph (15); presum bill (16)
Pharmacy inject drug e-h (37, 38); presum bill (16)
Rehabilitation Clinics inject drug e-h (37, 38); modif used (13); non ph (15)

8. 2020 Clinical Lab Rate Updates

Effective retroactively for dates of service on or after January 1, 2020, rates for select clinical laboratory or laboratory services are adjusted to 80 percent of the lowest maximum allowance established by the federal Medicare rate program for the same or similar services, in accordance with Welfare and Institutions Code (W&I Code), Section 14105.22(b). Providers may refer to the Medi-Cal Rates page on the Medi-Cal Provider website for rates.

No action is required of providers. An Erroneous Payment Correction will be initiated to automatically correct reimbursement, as appropriate, for claims already submitted.

9. 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 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    Naloxegol Oxalate Effective date changed    drugs cdl p1c (3)
January 1, 2021 Insulin Degludec Strength added drugs cdl p1b (64)
January 1, 2021 Insulin Detemir (rDNA Origin) Strength removed,
administration removed
drugs cdl p1b (64)
February 1, 2021    Colchicine Restriction removed drugs cdl p1a (72)
February 1, 2021 Eslicarbazepine Acetate Restriction added drugs cdl p1b (15)
February 1, 2021 Fludarabine Phosphate Restriction removed drugs cdl p1b (29)
February 1, 2021 Glucagon (r-Dna Origin)    Restriction added drugs cdl p1b (45)
February 1, 2021 Ombitasvir/
Paritaprevir/
Ritonavir/
Dasabuvir
Restriction changed drugs cdl p1c (24)

10. Clinical Review: Recommendations for the Management of Acute Dental Pain

A new DUR Educational Article titled “Clinical Review: Recommendations for the Management of Acute Dental Pain (PDF format)” is available on the DUR: Educational Articles page of the Medi-Cal website.

11. Physician-Administered Drugs Update

The Physician-Administered Drugs section of the Pharmacy provider manual is updated. A summary of drugs that are changed or deleted is shown below.

Changed Drug(s)
Effective Date Drug Summary of Changes
January 1, 2021    Buprenorphine Extended Release   
Injectable Solution
Note added
January 1, 2021 Naltrexone Extended Release
Injectable Suspension
Note added


Provider Manual(s) Page(s) Updated
Pharmacy physician (1, 2)

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13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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