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Medi-Cal Update

Pharmacy | May 2021 | Bulletin 991

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1. New NDC for Moderna COVID-19 Vaccine

Moderna has introduced a new National Drug Code (NDC), 80777027315, for their coronavirus disease 2019 (COVID-19) vaccine. Medi-Cal will accept and adjudicate pharmacy claims for dates of service on or after April 1, 2021, that use this NDC when billing for the administration of either dose of the Moderna COVID-19 vaccine.

The Moderna COVID-19 Vaccine web page is updated to reflect this change. All other billing policy, regardless of NDC billed, remains unchanged.

2. Emergency Use Authorization for Monoclonal Antibody Bamlanivimab Revoked

Effective for dates of service on or after April 16, 2021, the U.S. Food and Drug Administration (FDA) revoked the emergency use authorization (EUA) that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults and certain pediatric patients. Based on its ongoing analysis of emerging scientific data, specifically the sustained increase of SARS-CoV-2 viral variants that are resistant to bamlanivimab alone resulting in the increased risk for treatment failure, the FDA has determined that the known and potential benefits of bamlanivimab, when administered alone, no longer outweigh the known and potential risks for its authorized use. Therefore, the agency determined that the criteria for issuance of an authorization are no longer met and has revoked the EUA.

More information can be found in the FDA news release on the subject.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (12); immun cd (1, 3)

3. CCS Service Code Groupings Policy Update

The following codes will be added to or end-dated from the California Children's Services (CCS) Service Code Groupings (SCGs):

Added Codes

Effective Date Codes SCGs
January 1, 2021 Proprietary Laboratory Analyses (PLA) codes 0001A, 0002A, 0011A, 0012A and 0031A 01, 02
January 1, 2021 CPT® codes 94726 and 94729 01
January 1, 2021 CPT code 92523 05

End-Dated Codes

Effective Date CPT Codes SCGs
January 1, 2021 76970, 78135, 94250, 94400, 94750 and 94770 01
January 1, 2021 32405 and 81545 02
January 1, 2021 92585 and 92586 01, 04, 05, 06

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
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child ser (6, 14, 23, 24, 28, 32, 34, 36, 37)

4. BCCTP Applicants Granted Presumptive Eligibility

In the continued effort to align all Presumptive Eligibility (PE) Programs, Breast and Cervical Cancer Treatment Program (BCCTP) applications granted PE will populate in the Medi-Cal Eligibility Data System (MEDS) with an automated termination date of the end of the following month. As soon as the applicant fulfills the requirement to apply for full-scope Medi-Cal benefits from their county, this termination date will drop off and they will continue in PE until BCCTP makes the continuing eligibility decision. Also, the plastic Benefits Identification Card (BIC) will be issued when BCCTP makes the continuing eligibility decision. The “Confirmation Document” that is generated when Every Woman Counts (EWC) and Family Planning, Access, Care and Treatment (Family PACT) providers submit a BCCTP Enrollment Application should be used to obtain services by Medi-Cal providers during the PE period.

Providers are expected to hand-deliver, email or mail out to a BCCTP applicant, the “Confirmation Document” and the “Directions to Apply for Medi-Cal” that are generated together when the application is submitted. The “Confirmation Document” tells the applicants if they were granted PE and gives them their BIC number so they can obtain services. The “Directions of Apply for Medi-Cal” explains what the applicants must do in order for their benefits to continue beyond the end of the following month and serves as a notification that the benefits will terminate if they do not comply.

Questions concerning BCCTP PE should be sent to BCCTP@dhcs.ca.gov.

5. Assessment and Intervention CPT Codes Are no Longer PE4PW Benefits

Effective for dates of service on or after June 1, 2021, the following CPT® codes for health and behavior assessments and interventions are no longer benefits under the Presumptive Eligibility for Pregnant Women (PE4PW) program:

CPT Code Description
96156 Health behavior assessment, or re-assessment (for example, health-focused clinical interview, behavioral observations, clinical decision making)
96158 Health behavior intervention, individual, face-to-face; initial 30 minutes
96159 Health behavior intervention, individual, face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96164 Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes
96165 Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
96168 Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96170 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
96171 Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
presum bill (11, 12)

6. Medi-Cal Rx Subscription Service and Pharmacy Service Representative Phone Campaign

In preparation for the eventual transition of pharmacy claim administration to Medi-Cal Rx, the Medi-Cal Rx Subscription Service (MCRxSS) is available and the Pharmacy Service Representative Phone Campaign has been activated for all Medi-Cal Rx providers, including pharmacies, prescribers and their staff.

Medi-Cal Rx Subscription Service

The MCRxSS is a free service that provides the latest Medi-Cal Rx news, including upcoming training and outreach events. Current Medi-Cal providers, pharmacies, prescribers and their staff are encouraged to sign up for MCRxSS to stay informed of the latest pharmacy news. Subscribers will receive subject-specific emails for urgent announcements and other updates shortly after they are posted to the Medi-Cal Rx website. Individuals can sign-up for this service at the following address on the MCRxSS sign up page on the DHCS website.

Pharmacy Service Representative Phone Campaign

Pharmacy Service Representatives (PSRs) will be reaching out to prescribers via a phone call to introduce the new Medi-Cal Rx website and its available resources. If you are a prescriber and have started the User Administration Console (UAC) registration process, but have not completed it, please anticipate a phone call from a PSR to assist and answer questions. The PSRs will provide guidance on how to start registration for the secure provider portal and inform prescribers of available training and resources for Medi-Cal Rx.

7. Medi-Cal Rx Pharmacy Provider and Prescriber Readiness Survey

How do you and your peers currently conduct business for Medi-Cal Pharmacy Claims?

In preparation for the eventual transition of pharmacy claim administration to Medi-Cal Rx, the Medi-Cal Rx Education & Outreach Team would love to hear from you! The results of the Medi-Cal Rx Pharmacy Provider & Prescriber Readiness Survey will be used to tailor our training offerings for Medi-Cal Rx to ensure you are prepared for the upcoming transition. The information you provide is confidential and will be used only for future training.

8. Updated Rates for Select Physician Administered Drugs

Effective for dates of service on or after January 1, 2021, rates are updated for claims billed with HCPCS code J3490 (unclassified drugs) and modifier U6 (levonorgestrel) or U8 (medroxyprogesterone acetate).

Procedure Code with Modifier Description Rate
J3490 U6 Levonorgestrel, 1.5 mg $13.85
J3490 U8 Medroxyprogesterone acetate, 150 mg $64.61

Providers should refer to the Medi-Cal Rates page of the Medi-Cal website for general rates information.

9. Policy Update for HCPCS Code E0616

Effective for dates of service on or after June 1, 2021, HCPCS code E0616 (implantable cardiac event recorder with memory, activator and programmer) is designated as a surgical device or supply. Providers should no longer use HCPCS code E0616 to bill for services related to durable medical equipment, orthotics or prosthetics.

Previously, a frequency limit of once in a lifetime was established for HCPCS code E0616. A frequency limit is no longer applicable and modifiers NU, T1-T9, TA and UE are no longer allowed.

Provider Manual(s) Page(s) Updated
Durable Medical Transportation
Orthotics and Prosthetics
Therapies
Pharmacy
dura cd fre (3)

10. 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.

11. Provider Manual Revisions



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