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Effective retroactively for dates of service on or after November 1, 2015, reimbursement for factor X preparations requires a separate Service Authorization Request (SAR) for the California Children's Services (CCS)/Genetically Handicapped Persons Program (GHPP).
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, the current HCPCS Local Level III codes for Home Health Agencies (HHA) will be discontinued. The codes will be replaced by 11 new Health Insurance Portability and Accountability Act (HIPAA) compliant national and revenue codes. The HCPCS national code and revenue code will be required on all home health claims.
Every new Treatment Authorization Request (TAR) and electronic TAR (eTAR) submitted with dates of service on or after June 1, 2016, must include the HCPCS codes described below; the revenue code is not required. The Department of Health Care Services (DHCS) will provide directions at regular intervals, reminding providers to exhaust existing TARs and Service Authorization Requests (SARs).
Providers should review their inventory for previously approved TARs with HHA services that have dates of service on or after June 1, 2016. For those TARs, providers must submit a new TAR or eTAR with the appropriate HCPCS code to cover any remaining service period on or after June 1, 2016.
If the submitted TAR is for the purpose of updating the codes for the same authorization period, it will not be reviewed for medical necessity.
The conversion is as follows:
Includes supplies that are used as part of the treatment visit.
No limit on the number of daily visits.
Limited to 40 15-minute increments per day
Limited to one visit per day or four 15-minute increments.
Limited to one visit per day or four 15-minute increments.
Limited to one visit per day or four 15-minute increments.
Limited to one visit per day or four 15-minute increments.
Respiratory therapist services can be authorized and billed under 99600.
CPT-4 code 99502 Home visit for newborn care and assessment
Does not require a TAR.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after April 1, 2016, the following diabetes self-management training (DSMT) HCPCS codes are Medi-Cal benefits:
The frequency restrictions for claims paid in the first continuous 12 months (one year) and subsequent years have been updated in the provider manual.
Claims with additional number of hours are to be billed with a Treatment Authorization Request (TAR), California Children's Services (CCS)/Genetically Handicapped Persons Program (GHPP) stamp or CCS Service Authorization Request (SAR).
HCPCS codes G0108 and G0109 may not be billed on the same date of service as CPT-4 codes 97802 97804.
Effective for dates of service on or after April 1, 2016, the following medical nutrition therapy (MNT) CPT-4 codes are Medi-Cal benefits:
Claims with additional number of hours are to be billed with a TAR, CSS/GHPP stamp, or CCS SAR.
CPT-4 codes 97802 97804 may not be billed on the same date of service as HCPCS codes G0108 and G0109.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, genetic testing for maturity onset diabetes of the young (MODY) is reimbursable under the following CPT-4 codes as a new Medi-Cal benefit:
Reimbursement for MODY requires an approved Treatment Authorization Request (TAR) and requires providers to document the following on the TAR:
This information is reflected in the following provider manual(s):
Effective retroactively for dates of service on or after October 1, 2015, select HCPCS and CPT-4 codes are no longer split billable. Claim lines with the following codes must not be billed with modifiers 26, TC or 99, and do not require a modifier:
This information is reflected in the following provider manual(s):
Effective retroactively for dates of service on or after September 1, 2012, policy language and billing instructions are updated in the provider manual for Healthcare Common Procedure System (HCPCS) codes J1950 (injection, leuprolide acetate [for depot suspension], per 3.75 mg) and J9217 (leuprolide acetate [for depot suspension], 7.5 mg).
For claims denied with dates of service on or after September 1, 2012, providers may submit new claims for denials due to incorrect coding of HCPCS codes J1950 or J9217. Providers may also submit new claims for denials due to incorrect billing with J9217 in place of J1950 or vice versa. To initiate a new claim, providers must submit a Claims Inquiry Form (CIF) to void the previously denied claim. Both the CIF and new claim must be submitted together.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after January 1, 2016, HCPCS code J9299 (injection, nivolumab, 1 mg) replaces terminated HCPCS code C9453 (injection, nivolumab, 1 mg). The following are indications for the treatment of patients 18 years of age and older:
Recommended dosage instructions vary dependent upon the administration combination with ipilimumab.
The code requires an approved Treatment Authorization Request (TAR). Affected claims will be reprocessed.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, policy for HCPCS code J9047 (injection, carfilzomib, 1 mg) has been updated.
Carfilzomib is indicated for the treatment of multiple myeloma and is limited to patients 18 years of age and older.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after July 1, 2016, HCPCS codes C9137 (injection, factor VIII [antihemophilic factor, recombinant] PEGylated, 1 I.U.) and C9138 (injection, factor VIII [antihemophilic factor, recombinant] [Nuwiq], 1 I.U.) are Medi-Cal benefits. To bill for injection, factor VIII or injection, factor VIII (Nuqwiq), providers should now use codes C9137 and C9138, respectively, instead of HCPCS code J7199 (hemophilia clotting factor, not otherwise classified).
This information is reflected in the following provider manual(s):
Effective January 1, 2016, through December 31, 2016, Presumptive Eligibility (PE) for Pregnant Women providers must use the following income eligibility guidelines to make PE for Pregnant Women determinations.
This information is reflected in the following provider manual(s):
The Department of Health Care Services (DHCS) identified a claims processing issue causing claims billed with the following CPT-4 codes to deny when billed in conjunction with ICD-10-CM diagnosis codes O09.521 O09.523 (supervision of elderly multigravida):
This issue affects claims with dates of service on or after October 1, 2015.
DHCS will notify providers when the issue is resolved. Providers should continue to submit claims timely. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.
An article in the February 2016 Medi-Cal Update announced that, effective for dates of service on or after March 1, 2016, reimbursement for screening mammograms is restricted to females 50 to 74 years of age. This announcement was not compliant with the Consolidated Appropriations Act of 2016 (House Resolution 2029).
Providers should continue to supply mammography services. Breast cancer screening mammography for females 40 years of age and older, by any provider, once a year is reimbursable.
Retroactive to September 1, 2013, Medi-Cal's policy on reimbursement for screening mammograms is consistent with the U.S. Preventive Services Task Force's 2002 recommendation of breast cancer screening mammography every year for women 40 years of age and older. The revised policy applies to the following codes:
There are no diagnostic restrictions for screening mammograms. An approved Treatment Authorization Request (TAR) may override gender restrictions. Providers should continue to submit claims timely.
Denied claims for males for codes 77052, 77057 and G0202 will be reviewed retroactive to September 1, 2013. If authorization was documented, these claims will be reprocessed through the Erroneous Payment Correction (EPC) process.
Providers should continue to check the Medi-Cal website regularly for updates.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, CPT-4 codes 81519 (oncology [breast], mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score) and 81599 (unlisted multinalyte assay with algorithmic analysis) are Medi-Cal benefits.
Codes 81519 and 81599 have a frequency limit of once in a lifetime and require a Treatment Authorization Request (TAR) with documentation of the following:
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, a sterilization Consent Form (PM 330) and an approved Treatment Authorization Request (TAR) are required for the following CPT-4 codes, when the procedure will result in sterilization:
For all procedures that ensure sterilization, including unilateral procedures for patients who only have one ovary, testicle or vas, a PM 330 is required. Additional information about requirements for these procedures is located in the Sterilization section of the Part 2 provider manual.
This information is reflected in the following provider manual(s):
Bayer Corporation acquired Conceptus in 2013. Bayer provides the Essure System ESS305, a micro-insert procedure billed under CPT-4 code 58565 (hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants).
This information is reflected in the following provider manual(s):
Effective for dates of service on or after April 1, 2016, HCPCS code C9461 (choline C 11, diagnostic, per study dose) is a new Medi-Cal benefit. Allowable modifiers are 99 and U7. An invoice is required for reimbursement.
This information is reflected in the following provider manual(s):
Providers are encouraged to access the California Department of Public Healths (CDPH) Zika Web page, which continues to publish updates about Zika virus. Some of the available resources include Zika Virus FAQs for Health Care Providers, a Zika Questions and Answers fact sheet for the general public and a colorful, ready-to-print Zika and Pregnancy poster. Some resources are also available in Spanish.
CDPH asks that providers and their staff #TalkZIKA by sharing and retweeting social media messages. Providers can follow CDPH on Facebook (English and Spanish pages) and Twitter. In addition, providers can promote and provide Zika facts by adding the following clickable graphic to their email signatures, by simply copying the graphic and pasting using the Keep Source Formatting option. Clicking the image opens the CDPH Zika Web page.
Effective for dates of service on or after June 1, 2016, reimbursement for hormone injections used in the treatment of malignant neoplasms does not require an ICD-10-CM diagnosis code.
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, the Department of Health Care Services (DHCS) has updated the Treatment Authorization Request (TAR) requirement for bariatric surgery. This procedure is no longer required to be performed in a Centers for Medicare and Medicaid Services (CMS) certified Center of Excellence (COE).
This information is reflected in the following provider manual(s):
Effective for dates of service on or after June 1, 2016, liver-lung and liver-heart transplants are Medi-Cal benefits. In order to be reimbursable for liver-lung and liver-heart transplantation, the institution must be a Medi-Cal approved Center of Excellence for liver-lung and liver-heart transplants.
Policy Updates for Liver Transplantations
Indications for Liver-Heart and Liver-Lung Transplants
This information is reflected in the following provider manual(s):
Effective retroactively for dates of service on or after November 1, 2014, rates for the following codes have changed:
An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.
Effective retroactively for dates of service on or after September 1, 2014, providers billing for CPT-4 code 29125 (application of short arm splint; static) are no longer required to submit an attachment for reimbursement. Providers should bill CPT-4 code 29125 with modifier AG (primary surgeon), SA (nurse practitioner rendering service in collaboration with a physician) or U7 (services rendered by physician assistant) to indicate their provider type.
An Erroneous Payment Correction will be implemented to reprocess affected claims.
A new DUR Educational Article titled Drug Safety Communication: Saxagliptin, Alogliptin and Risk of Heart Failure (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.
A new DUR Educational Article titled Clinical Review: Atypical Antipsychotics and Adverse Metabolic Effects (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.
A new DUR Educational Article titled Drug Safety Communication: New Safety Warnings Added to Prescription Opioids (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.
Effective immediately, unless otherwise directed by Medi-Cal, all paper Treatment Authorization Requests (TARs) should be sent to the following location:
TAR Processing Center 820 Stillwater Road West Sacramento, CA 95605-1630
If a provider submits a TAR to a field office, the TAR will be returned to the provider with instructions to send the TAR to the TAR Processing Center.
For TAR status or issues, providers may call the Telephone Service Center (TSC) at 1-800-541-5555. Providers outside of California may call (916) 636-1980.
Department of Health Care Services (DHCS) offers the Provider Manual on the Medi-Cal website in Microsoft Word format and as a ZIP (compressed file). The website also contains links to free software to view these file formats.
DHCS is exploring modernizing the Medi-Cal, Child Health and Disability Prevention (CHDP) and Family Planning, Access, Care and Treatment (Family PACT) provider manuals to reflect the shift to mobile computing.
This Provider Manual Survey will collect provider feedback on this modernization effort. Responses will help DHCS assess provider concerns about moving toward a more mobile-friendly platform. While participation is not required, DHCS encourages all providers to take the survey. All answered surveys will be kept confidential and anonymous.
The Medi-Cal and specialty program provider manuals include online indexes that assist providers in finding information in the provider manuals. The Medi-Cal website also includes an online search tool that allows providers to quickly search key words and locate appropriate policy information in the provider manuals.
The Department of Health Care Services (DHCS) is exploring an idea to retire the index sections from the Medi-Cal, Child Health and Disability Prevention (CHDP) and Family Planning, Access, Care and Treatment (Family PACT) provider manuals.
DHCS developed the Manual Indexes Survey to collect provider feedback. Responses will help DHCS assess any provider issues or concerns about retiring the indexes. While participation is not required, DHCS encourages all providers to take the survey. All answered surveys will be kept confidential and anonymous.
Providers should note an Acronyms and Abbreviations Glossary section will remain in the provider manuals to assist providers with acronyms, and the Medi-Cal website's search function will still be available for provider use.
Effective for dates of service on or after January 1, 2016, the Medi-Cal claims processing system has been updated to align medical transportation and physician administered drug codes to the National Correct Coding Initiative (NCCI) edits regarding Medically Unlikely Edits (MUEs).
For additional information on NCCI MUEs, providers may refer to the Medically Unlikely Edits page of the Centers for Medicare & Medicaid Services (CMS) website.
The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are valid for dates of service on or after April 1, 2016.
For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.
Beginning June 7, 2016, and continuing throughout the month of June, the Department of Health Care Services (DHCS) Fiscal Intermediary, Xerox State Healthcare, LLC (Xerox) invites providers to participate in Medi-Cal provider training webinars. The webinars will be:
Providers will also have the ability to print class materials and ask questions during the training sessions. For those who are unable to attend, all recorded webinars will be archived and made available for viewing on the MLP.
Excerpt from:
Medi-Cal: Medi-Cal Update - Clinics and Hospitals | May ...
