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Medi-Cal Update

Pharmacy | April 2021 | Bulletin 989

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1. CCS Service Code Groupings Update

The following codes will be added to the California Children’s Services (CCS) Service Code Groupings (SCGs).

Added Codes

Effective Date Codes SCGs
January 15, 2021 CPT Codes 87428, 87636, 87637, 87811 and HCPCS Code G2012 01, 02
January 15, 2021 CPT Codes 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171 02
January 15, 2021 HCPCS Codes L7510, L8621, L9900 04
January 15, 2021 HCPCS Code Q4081 09

Reminder:

SCG 02 includes all the codes in SCG 01, plus additional codes applicable only to SCG 02. SCG 03 includes all the codes in SCG 01 and SCG 02, plus additional codes applicable only to SCG 03. SCG 07 includes all the codes in SCG 01 plus additional codes applicable only to SCG 07.

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Community-Based Services
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and
Local Educational Agency
Inpatient Services
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (1, 2, 21, 23, 32, 34, 46)

2. Medi-Cal Coverage Under the COVID-19 Public Health Emergency

Under the continuous coverage requirements in the federal Families First Coronavirus Response Act (FFCRA), all Medi-Cal beneficiaries are maintained in their current aid codes until end of the coronavirus disease 2019 (COVID-19) public health emergency (PHE). As a reminder, individuals in pregnancy-related aid codes continue to remain eligible for non-pregnancy services, as appropriate, under current COVID-19 PHE protections. Providers are advised to continue submitting claims with applicable diagnosis codes.

Questions concerning eligibility under pregnancy-related aid codes during PHE should be sent to pregnancy@dhcs.ca.gov.

3. 2021 HCPCS Q2 Update

The 2021 Quarter 2 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 benefits are included in the list of updates.

The code updates are effective for dates of service on or after April 1, 2021. Please refer to the HCPCS Level I and II code book for complete descriptions of these codes.

Provider Manual(s) Page(s) Updated
Audiology speech cd (2, 3)
Chronic Dialysis Clinics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30)
Clinics and Hospitals
General Medicine
chemo drug a-d (13, 22–24); chemo drug p-z (27, 28); immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); medne tele (10, 12); modif used (11–14); non ph (10, 13–15, 30); presum bill (19); prop lab (1, 22, 57–59); radi dia (22); radi nuc (7); surg urin (5); tar and non cd0 (32)
Community-Based Adult Services
Therapies
occu cd (1); once (1–3); phys cd (3); speech cd (2, 3)
Inpatient Services tar and non cd0 (32)
Obstetrics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30); presum bill (19); prop lab (1, 22, 57–59); radi dia (22); radi nuc (7); surg urin (5); tar and non cd0 (32)
Pharmacy immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); presum bill (19)
Rehabilitation Clinics immun (5, 9, 12, 17–23); immun cd (1, 3); inject cd list (1, 3–5, 10, 11, 16, 21, 24); inject drug a-d (29); inject drug e-h (55–57); inject drug i-m (7, 23, 24, 34, 35); inject drug s-z (26–29); modif used (11–14); non ph (10, 13–15, 30); occu cd (1); once (1–3); phys cd (3); speech cd (2, 3)

4. Medi-Cal Pharmacy Provider Self-Attestation Period Now Open

On April 1, 2021, the online attestation period opened for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the reimbursement for covered outpatient drugs. By April 1, 2021, Medi-Cal pharmacy providers should have received a communication that includes the URL for the online attestation portal, as well as a unique login ID and password, by email, fax, or mail. If you have not received this communication, please call the Attestation Survey Hotline at 1-844-294-9982 or email CODSurvey@mercer.com.

As published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) has implemented a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this new methodology is a two-tiered professional dispensing fee based on a pharmacy provider’s total (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process, which is submitted electronically and must be repeated annually.

DHCS policy states that a claim is equivalent to a dispensed prescription; therefore, the attestation is the total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing fewer than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete this attestation in order to receive it.

The attestation period for the 2020 calendar year is open from April 1, 2021, to April 30, 2021. The attestation period ends at 11:59 p.m. on April 30, 2021, and no attestations will be accepted after that time. The attestation for the 2020 calendar year reporting period determines the professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service from July 1, 2021, through June 30, 2022.

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs, or may call the Attestation Survey Hotline at 1-844-294-9982, or email their questions to CODSurvey@mercer.com.

5. New Vaccines for Children (VFC) Benefit

Effective for dates of service on or after May 1, 2021, CPT® code 90697 (diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine [DTaP-IPV-Hib-HepB], for intramuscular use) is a Medi-Cal and Vaccines For Children (VFC) benefit.

Modifier SL is required when administering the vaccine supplied by the VFC program. Modifiers SA, SB, UD, U7 and 99 are allowed. Recipients must be between 6 weeks and 4 years of age (prior to the 5th birthday).

6. 2021 Income Eligibility Guidelines for PE4PW

Effective January 1, 2021 through December 31, 2021, Presumptive Eligibility for Pregnant Women (PE4PW) program providers must use the following income guidelines to make PE4PW eligibility determinations. Providers should disregard all previous PE4PW income eligibility guidelines charts.

Federal Poverty Level Chart for PE4PW
Effective January 1, 2021, through December 31, 2021

Number of Persons in Family Monthly Gross Family Income
(in dollars)
Annual Gross Family Income
(in dollars)
2 3,093 37,105
3 3,898 46,775
4 4,704 56,445
5 5,510 66,116
6 6,316 75,786
7 7,122 85,456
8 7,928 95,126
9 8,733 104,796
10 9,539 114,467
11 10,345 124,137
12 11,151 133,807
For family units of more than 12 members,
for each additional member, add:
806 9,671

 

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum (4)

7. 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 1, 2021
NDC Labeler Code Contracting Company's Name
24689 Apnar Pharma
60219 Amneal Pharmaceuticals
70512 Sola Pharmaceuticals
71127 Laboratoire Francais Du Fractionnement
71247 Innogenix, LLC
71308 Trevena, Inc.
71837 Partner Therapeutics, Inc.
72078 Mylan Institutional LLC
72089 Evoke Pharma Inc.
72516 Oryza Pharmaceuticals, Inc.
72570 Delsam Pharma LLC
72763 Estreno Pharmaceuticals LLC
72829 Rhythm Pharmaceuticals, Inc.
72974 Myovant Sciences, Inc.
73042 Y-MAbs Therapeutics, Inc.
73079 Eiger Biopharmaceuticals Inc.
73090 Eusa Pharma (US) LLC
73150 TG Therapeutics, Inc.
74676 Verity Pharmaceuticals Inc.
75626 Aurinia Pharma U.S, Inc.
78670 USWM, LLC
Terminations, effective April 1, 2021
NDC Labeler Code Contracting Company's Name
16103 Pharbest Pharmaceuticals, Inc.
24987 Covis Pharmaceuticals Inc.
28105 Hill Dermaceuticals, Inc.
49663 Raptor Therapeutics, Inc.
50484 Smith & Nephew, Inc.
57881 Galena Biopharma, Inc.
64116 Intermune Pharmaceuticals, Inc.
65847 Scios Inc.
68712 JSJ Pharmaceuticals
70868 Key Therapeutics, LLC
72245 Forte Bio-Pharma LLC
72508 Neopharma Inc.

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 (6, 7, 9, 11, 12, 14–16, 18–22)

8. Pen Needles Quantity Restrictions Change, Effective March 1, 2021

Effective for dates of service on or after March 1, 2021, pen needles quantity limits without authorization have been updated to allow 100 pen needles per claim with no more than three (3) claims in a 90-day period. Pen needles are used in conjunction with injection pens to deliver injectable medications into the body and are billed on a pharmacy claim using the contracted product’s National Drug Code (NDC). Please refer to the Medical Supplies Billing Codes, Units and Quantity Limits effective for dates of service on or after January 1, 2021, for contracted product information.

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10. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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