Medi-Cal Update

General Medicine | June 2020 | Bulletin 552

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1. COVID-19 Specimen Collection is a New Medi-Cal Benefit

Effective for dates of service on or after March 1, 2020, HCPCS Code C9803 (hospital outpatient clinic visit specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 [SARS-COV-2] [Coronavirus Disease COVID-19]) is a new Medi-Cal benefit. C9803 has a frequency limit of two collections per day and can be billed with any ICD-10-CM code. This code is a Presumptive Eligibility (PE) service and is not reimbursable when billed with codes G2023 or G2024.

An erroneous payment correction (EPC) will be initiated to reprocess affected claims.

Specific billing policy related to C9803 will be released in a future Medi-Cal Update.

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2. CLIA Waived Status Available to Certified Providers for COVID-19 Testing

Effective for dates of service on or after March 20, 2020, in accordance with the recently published guidance from the Centers for Medicare & Medicaid Services (CMS), claims for HCPCS codes U0002 and CPT® code 87635 may be billed with modifier QW to indicate the provider is performing the procedure using a Clinical Laboratory Improvement Amendments (CLIA)-waived test kit. Providers should ensure they have a valid, current CLIA certificate before submitting claims for these codes with the QW modifier.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

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3. New COVID-19 Specimen Collection Rate

In response to the coronavirus disease 2019 (COVID-19), the Centers for Medicare & Medicaid Services (CMS) established HCPCS code C9803 for specimen collection in a hospital outpatient clinic setting, among other codes. Accordingly, the Department of Health Care Services (DHCS) is establishing a reimbursement rate for the new code. The rate is based on the most recent corresponding Medicare rate, and is reimbursed at 100 percent of the Medicare rate. It is exempt from the ten percent payment reductions in Welfare and Institutions Code (W&I Code) Section 14105.192.

Upon expiration of the public health emergency or national emergency, this rate will be amended to correspond with the clinical laboratory services methodology in W&I Code Section 14105.22, including the application of the Assembly Bill 97 (AB 97) payment reduction.

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4. New Policy Changes to the Hospital Presumptive Eligibility Program

As California continues to respond to coronavirus disease 2019 (COVID-19), the Hospital Presumptive Eligibility (HPE) Program will temporarily expand presumptive eligibility (PE) coverage to a new coverage group of individuals who are 65 or older and whose income is below 138 percent of the Federal Poverty level (FPL), effective immediately. This new coverage group is referred to as the “Aged” HPE group. This coverage group is allowed two (2) periods of PE in a twelve-month period and will be assigned aid code 7D. This expansion will be in effect through the end of the COVID-19 public health emergency.

DHCS is also expanding presumptive eligibility periods through HPE for adults that are age 19 years and over. HPE will now provide two (2) periods of presumptive eligibility in a twelve-month period for adults age 19 and over. This change is effective immediately and will be in effect through the end of the COVID-19 public health emergency.

DHCS has received federal approval on these new policy changes through California State Plan Amendment 20-0024.

It is critical that HPE Providers monitor the Hospital PE Program Medi-Cal website for future articles and materials scheduled to publish during May and June 2020.

Questions concerning the HPE expansion should be sent to DHCSHospitalPE@dhcs.ca.gov.

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5. COVID-19 Diagnostic Testing CPT and HCPCS Codes Updated

In response to coronavirus disease 2019 (COVID-19), the Centers for Medicare & Medicaid Services (CMS) established HCPCS codes U0003 and U0004 and CPT® codes 86328, and 86769 for COVID-19 diagnostic testing services, among other codes.

The Department of Health Care Services (DHCS) is establishing reimbursement rates for the new codes. These rates are based on the most recent corresponding Medicare rates, and are reimbursed at 100 percent of the Medicare rate. Upon expiration of the public health emergency or national emergency, these rates will be amended to amounts that correspond with the clinical laboratory services methodology in Welfare and Institutions Code (W&I Code) Section 14105.22, including the application of the Assembly Bill 97 (AB 97) payment reduction.

The effective date of this policy update for HCPCS codes U0003 and U0004 is for dates of service on or after March 18, 2020, and for CPT codes 86328 and 86769 is dates of service on or after April 10, 2020.

An EPC letter will be issued for affected claims for codes U0003, U0004, 86328 and 86769 retroactive to dates of service on or after March 18, 2020, or April 10, 2020.

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6. New Medi-Cal Provider Website: Common Content and Locations

The Department of Health Care Services (DHCS) has implemented a new Medi-Cal Provider website.

Community Focus
The new Medi-Cal Provider website focuses on delivering content to specific provider communities. This is similar to the way in which content was broken up on the legacy website, but now each provider community with a provider bulletin and provider manual also have their own community web page. This community web page delivers content focused to each individual provider community. The Navigating Medi-Cal and Specialty Programs Chart outlines how these communities are organized.

The following provides a list of commonly visited content areas and their new locations on the new Medi-Cal Provider website. Please note that most of these items are also accessible via the Site Map link located in the footer of each web page.

Medi-Cal Update Bulletins and Provider Manuals
Monthly provider community-specific Medi-Cal Update bulletins and provider manuals are located within each tailored Medi-Cal provider community web page. These pages are located on the Medi-Cal Provider Publications web page and within the corresponding list of provider community tiles. All provider manuals, regardless of provider community, can be accessed via the References bar located within each provider community web page.

Medi-Cal News and Provider Letters
Medi-Cal news articles, previously known as NewsFlash articles, are available within the News bar located on each provider community web page. Provider Letters, such as Erroneous Payment Corrections (EPCs), are available via a link provided within the Site Map.

Transactions Services
Medi-Cal Internet Transactions can be accessed via several different paths. The first access point for Transactions Services is the Medi-Cal Internet Transactions tile located on the bottom half of the Medi-Cal Provider website’s home page. The second path is through the Providers tab within the website’s Navigation Bar located at the top of each web page.

Medi-Cal Learning Portal and Outreach & Education
The Medi-Cal Learning Portal (MLP) can be accessed via the Outreach & Education page located within the Providers tab of the Navigation Bar. The MLP can also be accessed via the MLP tile located on the bottom half of the Medi-Cal Provider website’s home page. The Outreach & Education web page also contains important information regarding Provider Training Workbooks, Provider Training Seminars and Webinars, as well as how to contact your Regional Representative and the Small Provider Billing Assistance and Training Program.

Medi-Cal Subscription Service
The Medi-Cal Subscription Service (MCSS), which includes both the MCSS Subscription Form and the MCSS Help Page, is accessible via the MCSS tile located on the bottom half of the Medi-Cal Provider website’s home page. As well, the MCSS can be reached by way of the Providers tab located within the Navigation Bar.

System Status Alerts
The new Medi-Cal Provider website features an all-new System Status Alert banner. The banner is located at the very top of each web page when a System Status Alert notification is in effect. The banner also offers a direct link to the System Status web page. The System Status web page can also be accessed via the Resources tab located within the Navigation Bar.

Medi-Cal Rates
Medi-Cal Rates are available within Featured Links which are located on the righthand side of each provider community web page. DHCS recommends that providers bookmark the provider community-specific web page(s) that they provide benefits and services to. These bookmarks will supply an ease of use when returning to the new Medi-Cal Provider website for future visits.

Frequently Asked Questions, Forms and References
Frequently Asked Questions (FAQs), Forms and References are each accessible via Featured Links on each provider community web page.

New Provider and Website Tour
DHCS is pleased to announce that the new Medi-Cal Provider website offers a New Provider web page where a New Provider Checklist, helpful links and reference documents are all posted. This new page will offer key information for all newly enrolled providers to the Medi-Cal program. The section is accessible via the Providers tab within the Navigation Bar located at the top of each web page.

In addition, DHCS has developed an all-new Medi-Cal Website Tour, which DHCS recommends all providers and website visitors view immediately upon their first visit to the new Medi-Cal Provider website. This tour provides a concise guided path around the most commonly visited areas and information available on the new website. The tour is located within the Resources tab of the Navigation Bar.

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7. New Benefit: Outpatient Treatment of Opioid Use Disorder

Effective for dates of service on or after July 1, 2020, the following HCPCS codes are new Medi-Cal benefits:

HCPCS Code Description
G2086 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
G2087 at least 60 minutes in a subsequent calendar month
G2088 each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)

HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one practitioner can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. More information is available in the Medicine: Telehealth section of the appropriate Part 2 Medi-Cal provider manual.

The codes are not reimbursable for treatment in an opioid treatment program.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (31); non ph (9)
Rehabilitation Clinics non ph (9)
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8. Policy Updated for Depression Screening

Effective for dates of service on or after July 1, 2020, HCPCS codes G8431 (screening for depression is documented as being positive and a follow-up plan is documented) and G8510 (screening for depression is documented as negative, a follow-up plan is not required) are reimbursable for pregnant and non-pregnant adults and children 12 years of age and older.

Billing for HCPCS code G0444 (annual depression screening, 15 minutes) will be denied with no Treatment Authorization Request (TAR) override available.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (29–30); prev (3)
Obstetrics eval (29)
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9. Triamcinolone Acetonide is a Medi-Cal Benefit

Effective for dates of service on or after July 1, 2020, HCPCS code J3304 (injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg) is a Medi-Cal benefit for recipients 18 years of age or older.

Modifiers LT (left side) and RT (right side) are required for reimbursement. Modifiers SA, UD, U7 and 99 are allowed.

An approved Treatment Authorization Request (TAR) is required for reimbursement.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (15); inject drug s-z (15, 16); modif used (12)

Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics

inject cd list (15); inject drug s-z (15, 16); modif used (12); non ph (13)
Pharmacy inject drug s-z (15, 16); inject cd list (15)
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10. Updates to HCPCS and CPT® Immunization Codes

Effective for dates of service on or after July 1, 2020, policy for multiple HCPCS and CPT immunization codes are updated.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
immun (1–30); immun cd (1, 2); vaccine (1, 2)
Pharmacy immun (1–30); immun cd (1, 2)
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11. Family Therapy is a Medi-Cal Benefit

Effective for dates of service on or after January 1, 2020, the following CPT® codes for family therapy are Medi-Cal benefits when rendered by a psychologist, Licensed Clinical Social Worker (LCSW), Licensed Professional Clinical Counselor (LPCC) or Marriage and Family Therapist (MFT). Family therapy is reimbursable for treatment of mental health conditions in children and adults. Family therapy is also reimbursable for prevention of mental health conditions in children with specified risk factors. For more information, refer to the Psychological Services section of the appropriate Part 2 manual.

CPT Code Description
90846 Family psychotherapy (without patient present), 50 minutes
90847 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90849 Multiple-family group psychotherapy
99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour
Note:

CPT code 99354 is only reimbursable when billed on the same date of service as CPT code 90847. In addition, CPT codes 90846, 90847, 90849 and 90853 may not be billed on the same day by the same provider for the same beneficiary.

An Erroneous Payment Correction (EPC) will be implemented for services billed with these CPT codes on or after January 1, 2020. Providers should continue to submit claims in a timely manner and are encouraged to check the Medi-Cal website regularly for updates.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Inpatient Services
Obstetrics
tar and non cd9 (1)
Psychological Services psychol (1–6); psychol cd (1)
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12. Andexanet Alfa (Andexxa) is a New Medi-Cal Benefit

Effective for dates of service on or after April 1, 2020, HCPCS code C9041 (Injection, coagulation Factor Xa [recombinant], inactivated [Andexxa], 10 mg) is a Medi-Cal benefit.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (2); inject drug a-d (5, 6)
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13. Updated Every Woman Counts Covered Procedure Forms

Effective for dates of service on June 1, 2020, the following Every Woman Counts Covered Procedure forms are being replaced on the Medi-Cal website.

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14. Correction to Split-Billed Radiology Reimbursement Rate Policy

Effective retroactively for dates of service on or after April 1, 2017, the radiology split-billing reimbursement rate will return to rates in place prior to April 9, 2020.

An Erroneous Payment Correction (EPC) will be implemented to reprocess effected claims. No action is required of providers.

The new rates will be released in a future Medi-Cal Update.

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15. Cystic Fibrosis Policy Updates

Effective for dates of service on or after July 1, 2020, the following cystic fibrosis codes have been updated:

CPT® Code Code Description Updated Information
81220 CFTR (cystic fibrosis transmembrane conductance regulator) gene analysis; common variants (e.g., ACMG/ACOG guidelines) Updated ICD-10-CM diagnosis codes
Z34.00 – Z34.03,
Z34.80 – Z34.83
Z34.90 – Z34.93,
O09.00 – O09.93
81221 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants

New Medi-Cal benefit and added to the PE4PW program

81222 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants) New Medi-Cal benefit and added to the PE4PW program
81223 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence New Medi-Cal benefit and added to the PE4PW program
81224 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) New Medi-Cal benefit
81329 SMN1 (survival of motor neuron 1, telomeric) gene analysis; dosage/deletion analysis, includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed Updated ICD-10-CM diagnosis code O09.00 – O09.93 and added to the PE4PW program

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
gene coun (4); path molec (14, 15, 30); presum bill (3); tar and non cd8 (2)
Pharmacy presum bill (3)
Inpatient Services tar and non cd8 (2)
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16. Chronic Care Management Policy Update

An error was identified which caused inappropriate denials of claims for CPT® code 99490.

An Erroneous Payment Correction (EPC) will be implemented to process any claims that were denied due to this error. Providers do not need to resubmit claims.

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17. Every Woman Counts Program Addition of New Data Entry Fields for DETEC

Effective for dates of service on or after July 1, 2020, the Every Woman Counts (EWC) Program will implement new data entry fields in the EWC data entry applications known as DETEC (DETecting Early Cancer). The collection of this data is required by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) of the Centers for Disease Control and Prevention (CDC).

The following data fields will be added to the Recipient Information screen:

The following changes will be made to the Breast Cancer Screening Cycle Data screen:

The following changes will be made to the Cervical Cancer Screening Cycle Data screen:

This update will be reflected in the Every Woman Counts Step-by-Step User Guide, to be released in a future Medi-Cal Update.

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18. Modifier Exclusion for Supplemental Payments for Some Family Planning Services

Effective retroactively for dates of service on or after July 1, 2019, supplemental payments will not be allocated under the California Healthcare Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) for the following specified Medi-Cal family planning services under the Medi-Cal fee-for-service program when billed with modifiers UA and UB.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

Procedure Code Description
11976 Removal, implantable contraceptive capsules
11981 Insertion, non-biodegradable drug delivery implant
58300 Insertion of intrauterine device (IUD)
58301 Removal of intrauterine device (IUD)
55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
58555 Hysteroscopy, diagnostic (separate procedure)
58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58600 Litigation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach
58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
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19. Update to Descriptor of Modifier CS

Effective for dates of service on or after March 1, 2020, the national modifier description for modifier CS is changed to “cost-sharing for specified COVID-19 testing-related services that result in an order for or administration of a COVID-19 test” from “item of service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.”

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Expanded Access to Primary Care Program
Home Health Agencies/Home and Community-Based Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Rehabilitation Clinics
Therapies
Vision Care
modif app (7)
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20. August 2020 Medi-Cal Provider Seminar

The August Medi-Cal provider seminar is scheduled for August 26 – 27, 2020, at the Sacramento Marriott Hotel in Sacramento, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the California MMIS Fiscal Intermediary, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by August 7, 2020, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After August 7, 2020, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks page of the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. To contact the regional representative for your area, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a regional representative.

Providers are encouraged to bookmark the Provider Training page and refer to it often for current seminar information.

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21. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs, Drugs: Contract Drugs List Part 2 – Over the Counter Drugs, Drugs: Contract Drugs List Part 3 – Over-the-Counter Cold/Cough Preparations.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 31, 2020 TAZEMETOSTAT Drug added drugs cdl p1d (11)
drugs cdl p4 (9)
June 1, 2020 GLIPIZIDE AND METFORMIN HCL Drug added, administration added, strength added drugs cdl p1b (30)
June 1, 2020 GLUCAGON (synthetic) Drug added, restriction added, administration added, strengths added drugs cdl p1b (30)
drugs cdl p4 (16)
June 1, 2020 POLYETHYLENE GLYCOL 3350 Strengths added and deleted drugs cdl p1c (35)
drugs cdl p2 (15)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
April 1, 2020 BUPRENORPHINE Restriction removed drugs cdl p1a (28)
April 1, 2020 BUPRENORPHINE/
NALOXONE
Restrictions removed drugs cdl p1a (29)
April 1, 2020 CHLOROQUINE Restriction added drugs cdl p1a (39)
April 1, 2020 HYDROXYCHLOROQUINE Restriction added drugs cdl p1b (36)
May 13, 2020 ACETAMINOPHEN Administrations added, restriction removed, strength added drugs cdl p2 (1)
June 1, 2020 CEFPODOXIME PROXETIL Restriction removed drugs cdl p1a (36)
June 1, 2020 GLIPIZIDE Administration added, strengths added drugs cdl p1b (30)
June 1, 2020 GLYBURIDE Administration added, strength added drugs cdl p1b (30)
June 1, 2020 INSULIN GLARGINE (rDNA origin) Restriction added, administration added, strength added drugs cdl p1b (42)
June 1, 2020 LEDIPASVIR/
SOFOSBUVIR
Strength added drugs cdl p1b (52)
June 1, 2020 METFORMIN HYDCROCHLORIDE Strength added drugs cdl p1b (68)
June 1, 2020 POLYETHYLENE GLYCOL 3350 Strength added and deleted drugs cdl p1c (35)
June 1, 2020 SOFOSBUVIR Strength added drugs cdl p1d (5)
July 1, 2020 INSULIN LISPRO, (rDNA ORIGIN) Administrations added strength added drugs cdl p1b (42)
July 1, 2020 INSULIN LISPRO PROTAMINE SUSPENSION/
INSULIN LISPRO INJECTION (rDNA ORIGIN)
Restriction added, administrations added, strength added drugs cdl p1b (42)
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22. Clinical Guideline: Reproductive Health in Rheumatic and Musculoskeletal Diseases

A new DUR Educational Article titled “Clinical Guideline: Reproductive Health in Rheumatic and Musculoskeletal Diseases” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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23. 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 March 19, 2020
NDC Labeler Code Contracting Company’s Name
72060 INTRA-CELLULAR THERAPIES, INC.

This information is reflected in the following provider manual(s):

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 (21)
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24. Incontinence Creams and Washes, Medical Supply Billing Codes Lists Updated

Effective for dates of service on or after March 16, 2020, a Treatment Authorization Request (TAR) is not required for reimbursement of incontinence cream and wash products billed with HCPCS codes A4335 (incontinence supply; miscellaneous) and A6250 (skin sealants, protectants, moisturizers, ointments, any type, any size) when prescribed by a physician for use in chronic pathological conditions causing the recipient’s incontinence (Code I Restriction). The List of Contracted Incontinence Creams and Washes and the List of Incontinence Medical Supply Billing Codes are updated to reflect this change.

A TAR or Service Authorization Request (SAR) is still required if claim quantity exceeds the frequency limits of 2,880 ml in an 81-day period for A4335 and 1,620 gm/ml in an 81-day period for A6250.

Providers are reminded that incontinence products supplied as refills are reimbursable if the product remains reasonable and necessary and the existing supply is nearly exhausted.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (1)
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25. Pharmacy Fee-For-Service Reimbursement Methodology for Blood Factors

Effective for dates of service on or after July 1, 2020, the Department of Health Care Services (DHCS) will implement a new fee-for-service reimbursement methodology for blood factors pursuant to California's State Plan Amendment (SPA) 19-0015, as approved by the Centers for Medicare & Medicaid Services (CMS) on January 20, 2019. Providers, as defined in Welfare and Institutions Code (W&I Code) Section 14105.86, will bill and be reimbursed for blood factors as outlined below.

Payment for blood factors purchased through and dispensed by a federally recognized Hemophilia Treatment Center (HTC) or its contracted pharmacy will be based on the lesser of:

Payment for blood factors purchased outside of a federally recognized HTC and dispensed by specialty pharmacies, Centers of Excellence or any other provider will be based on the lesser of:

This payment methodology is applicable to both pharmacy and non-pharmacy blood factor claims.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Chronic Dialysis Clinics
General Medicine
Pharmacy
blood (1)
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26. 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.

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27. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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