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Medi-Cal Update

Pharmacy | November 2022 | Bulletin 1027

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1. Bivalent Booster Dose Approved for Select COVID-19 Vaccines

Effective for dates of service on or after August 31, 2022, the U.S. Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for a Bivalent booster formulation for the Pfizer COVID-19 vaccine and Moderna COVID-19 vaccine, to be administered at least two months after either primary vaccination or booster dose with any authorized/approved monovalent COVID-19 vaccine, to the follow groups:

Pfizer-BioNTech COVID-19 Vaccine

Individuals 12 years of age or older as a single booster dose.

Moderna COVID-19 Vaccine

Individuals 18 years of age and older as a single booster dose.

For the most current direction regarding billing guidelines for the administration of the Bivalent booster dose, refer to the Pfizer-BioNTech COVID-19 Vaccine and Moderna COVID-19 Vaccine web pages.

For the most current information regarding Medi-Cal’s COVID-19 Response, see the COVID-19 Medi-Cal Response page on the Medi-Cal Provider website.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
immun (44–46, 48, 50, 50–53); immun cd (6, 8, 9)

2. Removal of Outdated Manual Sections and Addition of DPH Manual Sections

Effective retroactively on or after July 1, 2013, payment for inpatient general acute care hospitals (which do not participate in certified public expenditure reimbursement) has been based on a diagnosis-related groups (DRG) reimbursement methodology. The following five sections were retained in the Medi-Cal provider manual to accommodate claims submitted prior to July 1, 2013, and non-DRG reimbursed claims. These sections are now retired:

  • Contracted and Non-Contracted Inpatient Services

  • Contracted Inpatient Services for Allied Health

  • Contracted Inpatient Services for Medical Services

  • Obstetrics: Revenue Codes and Billing Policy

  • Obstetrics: UB-04 Billing Examples for Inpatient Services

Additionally, for information regarding Designated Public Hospitals (DPHs), i.e., those hospitals reimbursed through certified public expenditures (CPE) for acute inpatient care, the following three new provider manual sections have been added:

  • Designated Public Hospital Inpatient Services

  • Obstetrics: Revenue Codes and Billing Policy for Designated Public Hospitals

  • Obstetrics: UB-04 Billing Examples for Inpatient Services: Designated Public Hospitals

3. Pasteurized Donor Human Breast Milk Billable with HCPCS code T2101

Human Milk Bank

Effective for dates of service on or after December 1, 2022, Medi-Cal covers medically necessary pasteurized donor human milk (PDHM) milk when obtained from a licensed and approved facility. There are two Human Milk banks in California:

Centers for Disease Control and Prevention (CDC) has Guidelines for Proper Storage and Preparation of Breast Milk and Human Milk storage guidelines on the Breastfeeding Guidelines & Recommendations page on the CDC website.

Billing Code

HCPCS code T2101 (human breast milk processing, storage and distribution only), to be billed per ounce.

Criteria

Medi-Cal providers can arrange for the provision of PHDM for newborns in at least one of following situations:

  • Infant has documented birthweight of less than 1500 g

  • A congenital or acquired condition places the infant at risk for necrotizing enterocolitis (NEC) and/or infection

  • Infant has a qualifying condition determined by the neonatologist or pediatrician

  • Mother has a condition making their own milk insufficient in quantity or medically unsafe

  • Mother’s milk must be contraindicated, unavailable (due to medical or psychological condition), or available but lacking in quantity or quality to meet the infant’s needs

According to the American Academy of Pediatrics, human milk provides health benefits for all newborn infants but is of particular importance for high-risk infants, especially those born with very low birth weight (less than 1500 g). Donor human milk also can be beneficial to supplement the mother’s own milk as necessary. Recent studies support health benefits for its use in infants with birthweight less than 1500 g., especially in decreasing rates of NEC.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
epsdt (7); epsdt chdp (23); medne (17); preg com (6); preg post (7,8)
Durable Medical Equipment dura other (23,24)
Home Health Agencies/Home and
Community-Based Services
preg post (7,8)
Inpatient Services medne (17); ob rev instr (28); preg post (7,8)
Obstetrics epsdt (7); epsdt chdp (23); preg com (6); preg post (7,8)
Pharmacy dura other (23. 24); epsdt (7)

4. Updates to the List of O&P Codes

Effective for dates of service on or after December 1, 2022, the list of Orthotics and Prosthetics (O&P) codes has updated to include the following HCPCS codes:

  • L0120 (cervical, flexible, nonadjustable, prefabricated, off-the-shelf [foam collar])

  • L5859 (addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s))

  • L5990 (addition to lower extremity prosthesis, user adjustable heel height)

For the reimbursement rates of orthotic and prosthetic appliances, providers should refer to the Medi-Cal Rates page on the Medi-Cal Providers website.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Orthotics and Prosthetics
Pharmacy
Therapies
ortho cd1 (3); ortho cd2 (11, 12)

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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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