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Medi-Cal Update

Obstetrics | August 2021 | Bulletin 566

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1. CLIA-waived Status Available to Certified Providers for COVID-19 Codes

Effective retroactively for dates of service on or after October 6, 2020, in accordance with the recently published Medicare Learning Network (MLN) Matters MM12318 from the Centers for Medicare & Medicaid Services (CMS), claims for CPT® code 87637 and PLA codes 0240U and 0241U may be billed with modifier QW to indicate the provider is performing the procedure using a Clinical Laboratory Improvement Amendments (CLIA)-waived test kit. Providers should ensure they have a valid, current CLIA certificate before submitting claims for these codes with the QW modifier.

Codes affected are listed below:

CPT Code Description
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
0240U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected
0241U Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected

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
Chronic Dialysis Clinics
General Medicine
Obstetrics
path bil (16, 17)

2. HPE Off–Premise Flexibilities

Hospital Presumptive Eligibility (HPE) providers may complete HPE determinations off the premises of hospitals and clinics, such as in mobile clinics, street teams or other locations. In addition, hospitals may choose to use third-party vendors, contractors or subcontractors to help individuals complete the paper version of the HPE application off the premises outside of the hospital or clinic setting. Paper HPE applications completed off the premises however, must be given to the HPE provider for online submission through the HPE Application Portal.

Only employees registered under a hospital’s or clinic’s NPI who have completed the HPE Provider Computer Based Training may submit determinations through the HPE Application Portal.

Note: PE coverage begins on the day in which the HPE determination is made via submission through the HPE Application Portal. For activation of real-time HPE benefits, it is important that all paper applications completed off the premises of hospitals and clinics be given to the HPE provider daily for online submission into the HPE Application Portal immediately.

An HPE determination result must be relayed to the applicant immediately and a paper BIC provided if the applicant is determined eligible. If it is not possible to provide a paper BIC, the Client Identification Number (CIN) may be provided to the beneficiary verbally. All existing HPE requirements apply, whether the determination is made at a hospital or off-site.

HPE providers/employees are not permitted to delegate HPE determinations or use of the HPE Application Portal to non-hospital staff. Whether at the hospital or off-site, third-party vendors, contractors, subcontractors or county owned/operated clinic employees are not permitted to make HPE determinations or use the HPE Application Portal.

If HPE providers choose to use third-party vendors, contractors or subcontractors, the HPE providers must complete the HPE Provider Assistor Form and keep one on file. HPE providers may use third-party vendors, contractors or subcontractors to staff presumptive eligibility (PE) operations by staffing welcome desks, meeting with applicants and helping them complete the paper version of the HPE Application. However, third-party vendors, contractors or subcontractors are not permitted to make the PE determinations or use the HPE Application Portal.

Questions concerning off-premises HPE determinations should be sent to DHCSHospitalPE@dhcs.ca.gov.

3. Fumarate Hydratase Gene Test Added as a Medi–Cal Benefit

Effective for dates of service on or after September 1, 2021, FH (fumarate hydratase) (eg, fumarate hydratase deficiency, hereditary leiomyomatosis with renal cell cancer), full gene sequence, is added as a Medi-Cal benefit when billed under CPT® code 81405 (molecular pathology procedure, Level 6).

A valid Treatment Authorization Request (TAR) is required for reimbursement with the following criteria:

  • The patient presents with clinical symptoms and history suspicious for Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC), which may include one of the criteria below:

    • Multiple cutaneous leiomyomas, with at least one histologically confirmed lesion

    • Solitary cutaneous leiomyoma and family history of HLRCC

    • Presentation of severely symptomatic uterine fibroids before age 40

    • Presentation of Type II papillary renal cell cancer before age 40

    • Family history of first-degree family member meeting one of the above-mentioned criteria; and

  • The patient requires the service as a confirmatory test for HLRCC.
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path molec (57)

4. Correction: Pathology Benefit Article with Incorrect Effective Date Removed

The article New Pathology Benefits for Gene Analysis posted briefly on the Medi-Cal website on August 16, 2021. It was discovered the effective date in the article was inaccurate. The article was removed from the website and will publish at a later, more appropriate time with the correct effective date for the following services.

Code Description
81340 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction)
81341 TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot)
81342 TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s)

We are sorry for any inconvenience this has caused.

5. TAR Criteria Update for PLA Service Targeted Genomic Sequence Analysis

Effective for dates of service on or after September 1, 2021, the Treatment Authorization Request (TAR) criteria is updated for Proprietary Laboratory Analyses (PLA) code 0037U (targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden).

A TAR requires documentation of the following criteria:

  • The patient has either recurrent, relapsed, refractory, metastatic or advanced stages III or IV cancer, and

  • The patient either has not been previously tested using the same Next Generation Sequencing (NGS) test for the same primary diagnosis of cancer or repeat testing using the same NGS test only when a new primary cancer diagnosis is made by the treating physician, and

  • The decision for additional cancer treatment is contingent on the test results
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
prop lab (9)

6. Exceptions to Reimbursement Cutbacks for Select Office Consultation Codes

Effective retroactively for dates of service on or after January 1, 2016, reimbursement for CPT codes 99241 thru 99245 is not cutback to CPT codes 99212 thru 99215 when the claims have the primary or secondary ICD-10-CM diagnosis codes as any of the following.

  • O00 thru O9A.53

  • 71 thru Z03.79

  • 01

  • 1 thru Z36.9
Billed CPT Code Code Description
99241 Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99242 Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99243 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99245 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.

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 erroneously paid based on the cutback. 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
Rehabilitation Clinics
eval (13)

7. 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 and 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
August 1, 2021    Amivantamab-vmjw Drug added,
administration added,
restriction added   
drugs cdl p1a (14)
drugs cdl p4 (9)
August 1, 2021    Sotorasib Drug added,
administration added,
restriction added   
drugs cdl p1d (11),
drugs cdl p4 (12)
Effective Date Drug Summary of Changes Page(s) Updated
August 1, 2021    Avapritinib Dosages added    drugs cdl p1a (29)
August 1, 2021    Hydroxyurea Administration added,
restriction added
drugs cdl p1b (56)
August 1, 2021    Triptorelin Pamoate    Administration removed,
restriction added
drugs cdl p1d (43)

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9. Provider Manual Revisions



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