Effective for dates of service on or after March 1, 2020, HCPCS Code C9803 (hospital outpatient clinic visit specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-COV-2] [Coronavirus Disease COVID-19]) is a new Medi-Cal benefit. C9803 has a frequency limit of two collections per day and can be billed with any ICD-10-CM code. This code is a Presumptive Eligibility (PE) service and is not reimbursable when billed with codes G2023 or G2024.
An erroneous payment correction (EPC) will be initiated to reprocess affected claims.
Specific billing policy related to C9803 will be released in a future Medi-Cal Update.
Effective for dates of service on or after March 20, 2020, in accordance with the recently published guidance from the Centers for Medicare & Medicaid Services (CMS), claims for HCPCS codes U0002 and CPT® code 87635 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.
An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.
In response to the coronavirus disease 2019 (COVID-19), the Centers for Medicare & Medicaid Services (CMS) established HCPCS code C9803 for specimen collection in a hospital outpatient clinic setting, among other codes. Accordingly, the Department of Health Care Services (DHCS) is establishing a reimbursement rate for the new code. The rate is based on the most recent corresponding Medicare rate, and is reimbursed at 100 percent of the Medicare rate. It 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 97 (AB 97) payment reduction.
As California continues to respond to coronavirus disease 2019 (COVID-19), the Hospital Presumptive Eligibility (HPE) Program will temporarily expand presumptive eligibility (PE) coverage to a new coverage group of individuals who are 65 or older and whose income is below 138 percent of the Federal Poverty level (FPL), effective immediately. This new coverage group is referred to as the “Aged” HPE group. This coverage group is allowed two (2) periods of PE in a twelve-month period and will be assigned aid code 7D. This expansion will be in effect through the end of the COVID-19 public health emergency.
DHCS is also expanding presumptive eligibility periods through HPE for adults that are age 19 years and over. HPE will now provide two (2) periods of presumptive eligibility in a twelve-month period for adults age 19 and over. This change is effective immediately and will be in effect through the end of the COVID-19 public health emergency.
DHCS has received federal approval on these new policy changes through California State Plan Amendment 20-0024.
It is critical that HPE Providers monitor the Hospital PE Program Medi-Cal website for future articles and materials scheduled to publish during May and June 2020.
Questions concerning the HPE expansion should be sent to DHCSHospitalPE@dhcs.ca.gov.
The Department of Health Care Services (DHCS) has implemented a new Medi-Cal Provider website.
Community Focus
The new Medi-Cal Provider website focuses on delivering content to specific provider communities. This is similar to the way in which content was broken up on the legacy website, but now each provider community with a provider bulletin and provider manual also have their own community web page. This community web page delivers content focused to each individual provider community. The Navigating Medi-Cal and Specialty Programs Chart outlines how these communities are organized.
The following provides a list of commonly visited content areas and their new locations on the new Medi-Cal Provider website. Please note that most of these items are also accessible via the Site Map link located in the footer of each web page.
Medi-Cal Update Bulletins and Provider Manuals
Monthly provider community-specific Medi-Cal Update bulletins and provider manuals are located within each tailored Medi-Cal provider community web page. These pages are located on the Medi-Cal Provider Publications web page and within the corresponding list of provider community tiles. All provider manuals, regardless of provider community, can be accessed via the References bar located within each provider community web page.
Medi-Cal News and Provider Letters
Medi-Cal news articles, previously known as NewsFlash articles, are available within the News bar located on each provider community web page. Provider Letters, such as Erroneous Payment Corrections (EPCs), are available via a link provided within the Site Map.
Transactions Services
Medi-Cal Internet Transactions can be accessed via several different paths. The first access point for Transactions Services is the Medi-Cal Internet Transactions tile located on the bottom half of the Medi-Cal Provider website’s home page. The second path is through the Providers tab within the website’s Navigation Bar located at the top of each web page.
Medi-Cal Learning Portal and Outreach & Education
The Medi-Cal Learning Portal (MLP) can be accessed via the Outreach & Education page located within the Providers tab of the Navigation Bar. The MLP can also be accessed via the MLP tile located on the bottom half of the Medi-Cal Provider website’s home page. The Outreach & Education web page also contains important information regarding Provider Training Workbooks, Provider Training Seminars and Webinars, as well as how to contact your Regional Representative and the Small Provider Billing Assistance and Training Program.
Medi-Cal Subscription Service
The Medi-Cal Subscription Service (MCSS), which includes both the MCSS Subscription Form and the MCSS Help Page, is accessible via the MCSS tile located on the bottom half of the Medi-Cal Provider website’s home page. As well, the MCSS can be reached by way of the Providers tab located within the Navigation Bar.
System Status Alerts
The new Medi-Cal Provider website features an all-new System Status Alert banner. The banner is located at the very top of each web page when a System Status Alert notification is in effect. The banner also offers a direct link to the System Status web page. The System Status web page can also be accessed via the Resources tab located within the Navigation Bar.
Medi-Cal Rates
Medi-Cal Rates are available within Featured Links which are located on the righthand side of each provider community web page. DHCS recommends that providers bookmark the provider community-specific web page(s) that they provide benefits and services to. These bookmarks will supply an ease of use when returning to the new Medi-Cal Provider website for future visits.
Frequently Asked Questions, Forms and References
Frequently Asked Questions (FAQs), Forms and References are each accessible via Featured Links on each provider community web page.
New Provider and Website Tour
DHCS is pleased to announce that the new Medi-Cal Provider website offers a New Provider web page where a New Provider Checklist, helpful links and reference documents are all posted. This new page will offer key information for all newly enrolled providers to the Medi-Cal program. The section is accessible via the Providers tab within the Navigation Bar located at the top of each web page.
In addition, DHCS has developed an all-new Medi-Cal Website Tour, which DHCS recommends all providers and website visitors view immediately upon their first visit to the new Medi-Cal Provider website. This tour provides a concise guided path around the most commonly visited areas and information available on the new website. The tour is located within the Resources tab of the Navigation Bar.
Effective for dates of service on or after June 22, 2020, when submitting claims that include Other Health Coverage (OHC), providers must enter the actual amount collected from the OHC, including those that are negative.
Providers may refer to the updated NCPDP Payer Sheet Version 5.4 and the Pharmacy FAQs page of the Medi-Cal Provider website for more information. The updated Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual is available on the Medi-Cal Computer Media Claims (CMC) Billing and Technical Manual page of the Medi-Cal Provider website.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Pharmacy | compound comp (11); pcf30-1 comp (12) |
A previously published Medi-Cal Update bulletin article announced an Erroneous Payment Correction (EPC) related to denied claims for HCPCS codes E0465 and E0466 effective from October 1, 2016 to June 1, 2020. This EPC is delayed.
Providers need take no action but are encouraged to check the Medi-Cal website for further updates.
Effective for dates of service on or after July 1, 2020, HCPCS code J3304 (injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg) is a Medi-Cal benefit for recipients 18 years of age or older.
Modifiers LT (left side) and RT (right side) are required for reimbursement. Modifiers SA, UD, U7 and 99 are allowed.
An approved Treatment Authorization Request (TAR) is required for reimbursement.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics | inject cd list (15); inject drug s-z (15, 16); modif used (12) |
Clinics and Hospitals |
inject cd list (15); inject drug s-z (15, 16); modif used (12); non ph (13) |
| Pharmacy | inject drug s-z (15, 16); inject cd list (15) |
Effective for dates of service on or after July 1, 2020, policy for multiple HCPCS and CPT immunization codes are updated.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Rehabilitation Clinics |
immun (1–30); immun cd (1, 2); vaccine (1, 2) |
| Pharmacy | immun (1–30); immun cd (1, 2) |
Effective for dates of service on or after April 1, 2020, HCPCS code C9041 (Injection, coagulation Factor Xa [recombinant], inactivated [Andexxa], 10 mg) is a Medi-Cal benefit.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Chronic Dialysis Clinics Clinics and Hospitals General Medicine Obstetrics Pharmacy Rehabilitation Clinics |
inject cd list (2); inject drug a-d (5, 6) |
Effective for dates of service on or after July 1, 2020, the following cystic fibrosis codes have been updated:
| CPT® Code | Code Description | Updated Information |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) gene analysis; common variants (e.g., ACMG/ACOG guidelines) | Updated ICD-10-CM diagnosis codes Z34.00 – Z34.03, Z34.80 – Z34.83 Z34.90 – Z34.93, O09.00 – O09.93 |
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | New Medi-Cal benefit and added to the PE4PW program |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants) | New Medi-Cal benefit and added to the PE4PW program |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | New Medi-Cal benefit and added to the PE4PW program |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) | New Medi-Cal benefit |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) gene analysis; dosage/deletion analysis, includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed | Updated ICD-10-CM diagnosis code O09.00 – O09.93 and added to the PE4PW program |
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals General Medicine Obstetrics |
gene coun (4); path molec (14, 15, 30); presum bill (3); tar and non cd8 (2) |
| Pharmacy | presum bill (3) |
| Inpatient Services | tar and non cd8 (2) |
The August Medi-Cal provider seminar is scheduled for August 26 – 27, 2020, at the Sacramento Marriott Hotel in Sacramento, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.
Throughout the year, the Department of Health Care Services (DHCS) and the California MMIS Fiscal Intermediary, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:
Providers must register by August 7, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After August 7, 2020, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks page of the Medi-Cal website.
Note:Wi-Fi will not be provided at the seminar. Please plan accordingly.
Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.
Providers may also schedule a custom billing workshop. To contact the regional representative for your area, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.
Providers are encouraged to bookmark the Provider Training page and refer to it often for current seminar information.
Effective for dates of service on or after July 1, 2020, the Department of Health Care Services (DHCS) will implement a new fee-for-service reimbursement methodology for blood factors pursuant to California's State Plan Amendment (SPA) 19-0015, as approved by the Centers for Medicare & Medicaid Services (CMS) on January 20, 2019. Providers, as defined in Welfare and Institutions Code (W&I Code) Section 14105.86, will bill and be reimbursed for blood factors as outlined below.
Payment for blood factors purchased through and dispensed by a federally recognized Hemophilia Treatment Center (HTC) or its contracted pharmacy will be based on the lesser of:
Payment for blood factors purchased outside of a federally recognized HTC and dispensed by specialty pharmacies, Centers of Excellence or any other provider will be based on the lesser of:
This payment methodology is applicable to both pharmacy and non-pharmacy blood factor claims.
This information is reflected in the following provider manual(s):
| Provider Manual(s) | Page(s) Updated |
| Clinics and Hospitals Chronic Dialysis Clinics General Medicine Pharmacy |
blood (1) |
As has been published in a previous Medi-Cal Update, the Department of Health Care are Services (DHCS) did not resume retroactive pharmacy claim adjustments adjustments beginning with the February 10, 2020, checkwrite date. Recommencement of retroactive pharmacy claim adjustments due to a change in the reimbursement methodology for covered outpatient drugs will continue to be paused until further notice.
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!
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.
Pages updated due to ongoing provider manual revisions:
