Medi-Cal Logo

Medi-Cal Update

Obstetrics | July 2021 | Bulletin 565

Print Medi-Cal Update Print Icon
 

1. Sotrovimab (A Monoclonal Antibody) for COVID-19 Treatment Now a Benefit

Effective for dates of service on or after May 26, 2021, Sotrovimab has been authorized by the U.S. Food and Drug Administration (FDA) for use under an Emergency Use Authorization for the treatment of mild-to-moderate coronavirus 2019 (COVID-19) in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.

Unlike other monoclonal antibody therapies used for the treatment of COVID-19 whereby initial supplies were purchased and distributed free of charge by the Federal Government, Sotrovimab will be purchased by providers who must bill and be reimbursed for the cost of the product.

Providers may bill for the cost of administration (infusion) using Healthcare Common Procedure Coding System (HCPCS) codes M0247 (intravenous infusion, sotrovimab, includes infusion and post administration monitoring), M0248 (intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency) and for the cost of the product using Q0247 (injection, sotrovimab, 500 mg).

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (29–36); immun cd (1, 3); modif used (6); non ph (15, 30)
Chronic Dialysis Clinics immun (29–36); immun cd (1, 3); modif used (6)
Pharmacy immun (29–36); immun cd (1, 3)
 

2. In-Person Signature Requirement for Delivered Medications

In an April 28, 2020 article titled, “Temporary Suspension of In-Person Signature Requirement for Delivered Medications,” the Welfare and Institutions Code, Section 14043.341 requirement that “providers who dispense controlled drugs, dangerous drugs or dangerous devices to a Medi-Cal beneficiary to maintain a record of the signature of the person receiving the drug or device” was waived pursuant to Executive Order (EO) N-55-20 in response to the coronavirus disease 2019 (COVID-19) public health emergency.

EO N-55-20 will expire on June 30, 2021 per Governor Newsom’s most recent EO N-08-21 (issued June 11, 2021) to lift specific COVID-19-related executive orders that were put in place since March 2020. The Department of Health Care Services will end this policy change effective July 1, 2021 for all programs. Beneficiaries and clients, or their representatives, will need to sign for medications in person from their home or sign onsite at their provider location.

 

3. Correction to 2021 HCPCS Quarter 3 Update

The previously published Medi-Cal Update for the 2021 Quarter 3 Healthcare Common Procedural Coding System (HCPCS) codes, effective July 1, 2021, has been updated from the correction file recently released by the Centers for Medicare & Medicaid Services (CMS). HCPCS code C9065 was terminated and replaced by HCPCS code J9314, which was added as a new Medi-Cal benefit. CMS has sent an update reversing these changes. Code C9065 is no longer terminated and remains a Medi-Cal benefit, and code J9314 will not be implemented as a benefit in its place. Providers should continue to bill for services using code C9065 and not with code J9314.

Please refer to either the HCPCS Policy Updates PDF or the designated manual sections for more information.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (23); modif used (14)
General Medicine inject cd list (23); modif used (14); non ph (13,15); chemo drug p-z (25)
Clinics and Hospitals
Obstetrics
Rehabilitation Clinics
inject cd list (23); modif used (14); non ph (13,15)
 

4. New Telehealth Services and Various Changes to Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

Additionally, the following updates have been made to the Every Woman Counts (EWC) Provider Manual:

  • HCPCS code G0202 is no longer an EWC benefit; instead, providers should bill mammography screening using CPT® code 77067 (screening mammography, bilateral
    [2-view study of each breast], including computer-aided detection [CAD] when performed).

  • ICD-10-CM code Z12.72 (encounter for screening for malignant neoplasm of vagina; vaginal pap smear status-post hysterectomy for non-malignant condition) is added to the table of allowable Cervical Cancer Screening Codes.

  • ICD-10-CM code N93.1 (pre-pubertal vaginal bleeding) is removed from the table of allowable Cervical Cancer Screening and Diagnosis Codes.

  • The allowable ICD-10-CM codes for HCPCS code A4217 (sterile water/saline, 500 ml) are limited to those listed in Table 1b (Cervical Cancer Screening and Diagnosis ICD-10-CM Codes) and Table 2b (Breast Cancer Diagnosis ICD-10-CM Codes).

  • Category of Service (COS) 072 (breast only covered procedures) is eliminated from all EWC content and DHCS form 8471 Breast Only Primary Care Provider Covered Procedures is retired.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
ev woman (3, 18, 20–23, 25–32, 34–37, 40); ev woman exub (1)
 

5. Medi-Cal Provider Website: Future Enhancements and Changes

The Department of Health Care Services (DHCS) is committed to improving and enhancing the Medi-Cal Provider website. As such, DHCS launched its series of ongoing releases of enhancements, updates and changes to improve website navigation and user experience.

DHCS will incorporate Provider and Stakeholder feedback, industry best practices and California State web publishing guidelines when evaluating potential website changes. This new update includes:

  • Standardized website color scheme, font and formatting

  • Improved navigation and organization for Publications News, Provider Bulletins and Provider Manuals

  • Updated filters and sorting capabilities on the Medi-Cal News Articles page

  • Added ability for search to yield only News and Provider Bulletins content

A complete list of the enhancements, updates and additional website changes can be viewed within the Medi-Cal Provider Website Release Change Log (PDF file size 158 KB).

Providers are also encouraged to subscribe to the free Medi-Cal Subscription Service (MCSS). The MCSS allows each subscriber to choose and tailor both the subject matters and types of communications they wish to receive from the Medi-Cal Program.

 

6. Updated Rates for Hormone Containing Vaginal Rings

Effective for dates of service on or after April 1, 2021, rates are updated for claims billed with HCPCS code J7303 (contraceptive supply, hormone containing vaginal ring, each) and modifier U1 (etonogestrel and ethinyl estradiol) or U2 (segesterone acetate and ethinyl estradiol vaginal system), as follows:

Procedure Code with Modifier Description Rate
J7303 U1 Contraceptive vaginal ring, each (etonogestrel and ethinyl estradiol)  $121.62  
J7303 U2 Contraceptive vaginal ring (segesterone acetate and ethinyl estradiol vaginal system)  $2,090.00  
 

7. Radiology Reimbursement Rate Adjustment

Effective retroactively for dates of service on or after January 1, 2019 and January 1, 2020, radiology reimbursement rates have been adjusted.

In pursuant to Senate Bill 853 (Chapter 717, Statutes of 2010), the Department of Health Care Services (DHCS) is required to adjust Medi-Cal reimbursement rates for radiology services so they do not exceed 80 percent of the corresponding Medicare rate.

The updated radiology reimbursement rates are available on the Medi-Cal Rates page.

An Erroneous Payment Correction (EPC) will be implemented to reprocess claims with dates of service on or after the effective date of this billing policy that were appropriately submitted based on the guidance published in this article, but were paid based on the previously published rate.

 

8. Update to Minimum Age Limit for Colorectal Screening

Effective for dates of service on or after May 18, 2021, the CPT® code 81528 (oncology [colorectal] screening, quantitative real-time target and signal amplification of 10 DNA markers [KRAS mutations, promoter methylation of NDRG4 and BMP3] and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result) has an updated minimum age limit of 45 years of age per the latest U.S. Preventive Services Task Force recommendation for Colorectal Cancer Screening.

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriate adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Provider Manual.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (90)
 

9. Update to Allowable Specialized Services

Effective for dates of service on or after July 1, 2021, the list of specialized services that can be billed on an outpatient claim, even when provided on an inpatient basis, is updated. Existing policy currently in place for other allowable specialized services shall remain in place.

Blood Factors HCPCS Code Effective Dates Notes
Blood Factor X J7175 July 1, 2021 N/A
Blood Factor Von Willebrand J7179 July 1, 2021 N/A
Blood factor XIII Antihemophilic factor J7181 July 1, 2021 Replaces C9134
Blood Factor VIII/Noveoeight J7182 July 1, 2021 N/A
Blood Factor VIII J7204, J7205, J7211, J7207, J7208, J7209, J7210 July 1, 2021 N/A
Blood Factor VIII/Obizur J7188 July 1, 2021 N/A
Blood Factor VIIa/SevenFact J7212 July 1, 2021 Previously J7199
Blood Factor IX/Rixubis/Alprolix/Idelvion/Rebinyn J7200, J7201, J7202, J7203 July 1, 2021 N/A
Aprolix J7201 July 1, 2021 Previously J7199
Onasemnogen abeparvovec xioi (Zolgensma® J3399 July 1, 2021 Separate CCS authorization is required for outpatient administration

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Chronic Dialysis Clinics
Pharmacy
Rehabilitation Clinics
inject drug n-r (13)
Inpatient Services diagnosis ip (8)
 

10. Updated Rates for Select Physician-Administered Drugs

Effective for dates of service on or after April 1, 2021, reimbursement rates are updated for claims billed with HCPCS code J3490 (unclassified drugs) with the following modifiers:

Procedure Code with Modifier Description Rate
J3490 U5 Ulipristal acetate, 30 mg $34.28
J3490 U6 Levonorgestrel, 1.5 mg $9.28
J3490 U8 Medroxyprogesterone acetate, 150 mg/ml $41.42

An Erroneous Payment Correction (EPC) will be implemented to reprocess denied claims with dates of service on or after the effective date of this billing policy, that were appropriately submitted based on the guidance published in this article, but erroneously denied because Medi-Cal had not yet implemented the system changes to support appropriation and adjudication. Providers may also elect to use this updated billing policy to correct and resubmit previously denied claims as described in the CIF Submission and Timeliness Instructions section of the Part 2 Medi-Cal Provider Manual.

 

11. September Virtual Claims Assistance Room Events

Receive free one-on-one billing assistance at our Virtual Claims Assistance Room (CAR) event scheduled for the month of September.

Multiple morning and afternoon sessions are available.

Providers must register through the Mediā€‘Cal Learning Portal Event Calendar.

Reminder: First time users must complete a one-time registration. For instructions on how to enroll in one of these sessions, use the link to the short video in the descriptive text on the “Provider Seminars and Webinars” tile on the Medi-Cal Learning Portal home page.

Providers are encouraged to bring their more complex billing issues to receive individual assistance from a Provider Field Representative.

For additional assistance, please contact the Telephone Service Center (TSC) at 1-800-541-5555.

 

12. 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.

Added Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
February 27, 2021    Janssen Coronavirus Disease 2019 (COVID-19) Vaccine Drug added,
administration added,
restriction added   
drugs cdl p1a (73)
April 1, 2021    Umbralisib Drug added,
administration added,
restriction added   
drugs cdl p1d (44),
drugs cdl p4 (12)
April 5, 2021 Melphalan Flufenamide Drug added,
administration added,
restriction added
drugs cdl p1b (97),
drugs cdl p4 (11)
April 13, 2021    Tivozanib Drug added,
administration added,
restriction added   
drugs cdl p1d (32),
drugs cdl p4 (12)
July 1, 2021 Apremilast Drug added,
administration added,
restriction added
drugs cdl p1a (22),
drugs cdl p4 (32)
July 1, 2021    Dostarlimab-gxly Drug added,
administration added,
restriction added   
drugs cdl p1a (97),
drugs cdl p4 (10)
July 1, 2021 Elagolix Drug added,
administration added,
restriction added
drugs cdl p1b (2),
drugs cdl p4 (23)
July 1, 2021    Elagolix,
Estradiol,
and Norethindrone Acetate
Drug added,
administration added,
restriction added   
drugs cdl p1b (2),
drugs cdl p4 (23)
July 1, 2021 Etanercept Drug added,
administration added,
restriction added
drugs cdl p1b (19),
drugs cdl p4 (32)
July 1, 2021    Evolocumab Drug added,
administration added,
restriction added   
drugs cdl p1b (23),
drugs cdl p4 (30)
July 1, 2021 Fremanezumab-vfrm Drug added,
administration added,
restriction added
drugs cdl p1b (38),
drugs cdl p4 (14)
July 1, 2021    Lactic Acid,
Citric Acid,
and Potassium Bitartrate
Drug added,
administration added,
restriction added   
drugs cdl p1b (75),
drugs cdl p4 (22)
July 1, 2021 Perampanel Drug added,
administration added,
restriction added
drugs cdl p1c (42),
drugs cdl p4 (17)
July 1, 2021    Tepotinib Drug added,
administration added,
restriction added   
drugs cdl p1d (21),
drugs cdl p4 (12)

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
February 1, 2021    Semaglutide Strength added,
size added   
drugs cdl p1d (4)
July 1, 2021    Pralsetinib Restriction changed drugs cdl p1c (54)
May 10, 2021    Pfizer-BioNtech COVID-19 Vaccine    Restriction changed drugs cdl p1a (73)
 

13. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective April 5, 2021
NDC Labeler Code Contracting Company’s Name
73657 Oncopeptides, Inc.
   
Additions, effective April 13, 2021
NDC Labeler Code Contracting Company’s Name
45629 AVEO Pharmaceuticals, Inc
   
Additions, effective July 1, 2021
NDC Labeler Code Contracting Company’s Name
72888

Advagen Pharma Ltd

73462

G1 Therapeutics Inc

73153

Juno Therapeutics, Inc.

73336

Urovant Sciences, Inc.

69528

Metacel Pharmaceuticals

71511

Athena Bioscience LLC

73562

Nestle Healthcare Nutrition, Inc.

73129

Origin Biosciences, Inc.

73604

Kiniksa Pharmaceuticals (UK), Ltd.

80056

Intra-Sana Laboratories, LLC

80705 Tripoint Therapeutics
80644

Zealand Pharma A/S

79952

ADC Therapeutics America, Inc.

76478 Oak Pharmaceuticals, Inc
   
Terminations, effective July 1, 2021
NDC Labeler Code Contracting Company’s Name
71351 Brookfield Pharmaceuticals, LLC

36800

Topco Associates LLC

53270 Cangene Bio Pharma
Provider Manual(s) Page(s) Updated

Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics

drugs cdl p5 (7, 8, 11, 16, 17, 19–24)
 

14. 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.

 

15. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



Note:
Download PDF (Portable Document Format) reader from the Web Tool Box.