Correction: Nursing Local Codes Are Reimbursable for EPSDT Home Health

April 30, 2019

On January 1, 2019, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) home health services code conversion became effective. Published billing instructions offered suggested HIPAA-compliant national code equivalents to the previously used HCPCS Level III local codes.

Providers are advised not to bill HCPCS Level II codes T1030 and T1031 (nursing care, in the home) per diem codes and to instead continue using local codes Z5805 (EPSDT shared nursing RN) and Z5807 (EPSDT shared nursing LVN) in order to receive the previous hourly rate.

Providers with Treatment Authorization Requests (TARs)/electronic TARs (eTARs) and Service Authorization Requests (SARs)/electronic SARs (eSARs) for national codes T1030 and T1031 will need to request for a new TAR/eTAR and SAR/eSAR using local codes Z5805 and Z5807.

Providers who have submitted claims with codes T1030 or T1031 will require a void and request subsequent resubmission of a corrected claim by using the two-step process.

  • The Claims Inquiry Form (CIF) void must be submitted to recoup the full payment (see the CIF Completion section in the Part 2 manual for details). Once the void appears on a future Remittance Advice Details (RAD), the provider completes the secondary step of submitting an appeal to request processing of the corrected claim.
  • The appeal must be submitted within 90 days of the date indicated on the RAD reflecting the void to avoid payment cutback or claim denial. Detailed appeal submission and documentation requirements are included in the Appeal Form Completion section of the Part 2 provider manual.

Details about this code conversion will continue to publish as determined. Continue to visit the HIPAA: Code Conversions page for EPSDT home health service updates in the NewsFlash area of the Medi-Cal website and in the monthly Medi-Cal Update.

Providers may complete the Medi-Cal Subscription Service (MCSS) Subscriber Form to receive timely notifications related to EPSDT home health services.