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Medi-Cal: Medi-Cal Update - Clinics and Hospitals | January 2011 | Bulletin 436
Medi-Cal Update - Clinics and Hospitals | January 2011 | Bulletin 436");
ifrm_doc.write(" Medi-Cal UpdateClinics and Hospitals | January 2011 | Bulletin 436Print Medi-Cal Update ");
ifrm_doc.write("ContentsMaternal Care Services Billing Code ConversionsMedical Services – Physician Subacute Care Billing Code Conversions Modifiers of Anesthesia Services Code ConversionComprehensive Perinatal Services Program Billing Code ConversionsMedical Abortion Billing Code ConversionsCDC Influenza Vaccine RecommendationsForm Removed from the Provider ManualCorrection: Diagnosis Code Requirements for Obstetrical UltrasoundsBRCA Analysis for Breast and Ovarian Cancer Policy and Benefit UpdatesGHPP Claims Now Submitted to DHCS Fiscal IntermediaryTrastuzumab Policy UpdateCCS Service Code Groupings UpdateGlucagon Code ConversionParathormone Billing LimitationsPayments During Demonstration Project ExtensionAdenosine Code ConversionEffective Implementation of ICD-10: Part II –Navigating IssuesRomiplostim Dosage AdjustmentProvider Orientation and Update SessionsAuthorized Drug Manufacturer Labeler Codes UpdateMedical Supply Products: Contracted Incontinence Creams and Washes Update E&M Observation Codes No Longer ReimbursableNo Documentation Required for Resuscitation Code Billed with NICU CodesUpdate: Medi-Cal Implementation of National Correct Coding InitiativePertussis Vaccine Recommendations BackgroundFulvestrant Code UpdatesDosage Update for Hylan G-F 20Modification to Echography and Radiological Ultrasounds Frequency RestrictionsAge Range Expanded for Tdap VaccineRadiology Rate ReductionHIPAA-Compliant Transaction Standards to Change Effective January 1, 2012Provider Manual Revisions");
Medi-Cal UpdateClinics and Hospitals | January 2011 | Bulletin 436Print Medi-Cal Update ContentsMaternal Care Services Billing Code ConversionsMedical Services – Physician Subacute Care Billing Code Conversions Modifiers of Anesthesia Services Code ConversionComprehensive Perinatal Services Program Billing Code ConversionsMedical Abortion Billing Code ConversionsCDC Influenza Vaccine RecommendationsForm Removed from the Provider ManualCorrection: Diagnosis Code Requirements for Obstetrical UltrasoundsBRCA Analysis for Breast and Ovarian Cancer Policy and Benefit UpdatesGHPP Claims Now Submitted to DHCS Fiscal IntermediaryTrastuzumab Policy UpdateCCS Service Code Groupings UpdateGlucagon Code ConversionParathormone Billing LimitationsPayments During Demonstration Project ExtensionAdenosine Code ConversionEffective Implementation of ICD-10: Part II –Navigating IssuesRomiplostim Dosage AdjustmentProvider Orientation and Update SessionsAuthorized Drug Manufacturer Labeler Codes UpdateMedical Supply Products: Contracted Incontinence Creams and Washes Update E&M Observation Codes No Longer ReimbursableNo Documentation Required for Resuscitation Code Billed with NICU CodesUpdate: Medi-Cal Implementation of National Correct Coding InitiativePertussis Vaccine Recommendations BackgroundFulvestrant Code UpdatesDosage Update for Hylan G-F 20Modification to Echography and Radiological Ultrasounds Frequency RestrictionsAge Range Expanded for Tdap VaccineRadiology Rate ReductionHIPAA-Compliant Transaction Standards to Change Effective January 1, 2012Provider Manual Revisions
1. Maternal Care Services Billing Code Conversions
Effective for dates of service on or after April 1, 2011, the Department of Health Care Services (DHCS) will discontinue the use of current Medi-Cal interim codes Z1030, Z1032, Z1034, Z1038 for maternal care services. These interim codes will be replaced by HIPAA-compliant CPT-4 codes and HCPCS code modifiers to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Part 162.1000.	The proposed national codes and modifiers were available for review and comments. The public forum began on November 1, 2010, and closed at 5 p.m. on December 15, 2010.
Providers must not bill the new coding standards until they are instructed to do so in future Medi-Cal Updates. The following changes are effective April 1, 2011: Interim Code
Interim Code Description Interim Code Rate Proposed National Code Modifier National Code Rate Billing Instructions
Z1030 Non-oxytocin fetal stress test $22.80 CPT Code
59020 – Fetal contraction stress test
52 – Reduced services $22.80
When 59020 is billed with modifier 52. A UB revenue code is required when billing on a UB-04 claim form or the 837-I transaction.
Z1032 Initial comprehensive pregnancy-related office visit $126.31 CPT Code
99205 – Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: comprehensive history; comprehensive examination; medical decision making of high complexity
99215 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: comprehensive history; comprehensive examination; medical decision making of high complexity
TH – Obstetrical treatment/services, prenatal or postpartum $126.31
When either 99205 or 99215 is billed with modifier TH. A UB revenue code is required when billing on a UB-04 claim form or the 837-I transaction.
Z1034 Antepartum visit $60.48 CPT Code
99201 – Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: problem focused history; problem focused examination; straightforward medical decision making
99212 – Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: problem focused history; problem focused examination; straightforward medical decision making
TH – Obstetrical treatment/services, prenatal or postpartum $60.48
When either 99201 or 99212 is billed with modifier TH. A UB revenue code is required when billing on a UB-04 claim form or the 837-I transaction.
Z1038 Postpartum office visit $60.48 CPT Code
59430 – Postpartum care only (separate procedure) $60.48 A UB revenue code is required when billing on a UB-04 claim form or the 837-I transaction.
2. Medical Services – Physician Subacute Care Billing Code Conversions Effective for dates of service on or after April 1, 2011, the Department of Health Care Services (DHCS) will discontinue the use of current Medi-Cal interim codes X9922, X9924, X9926, X9928, X9930, X9932, X9934, X9936, X9938, X9940, X9942, X9944, X9946, X9948, X9950, X9952, X9954, X9956, X9958, X9960, X9962, X9964, X9966, X9968 and X9970 for physician subacute care services. These interim codes will be replaced by HIPAA-compliant CPT-4 codes and a HCPCS code modifier to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Part 162.1000. The proposed national codes and modifier are now available for review and comments. The public forum begins on October 1, 2010, and will close at 5 p.m. on November 15, 2010. Providers can access the public forum by visitng the Public Comment Forum: Code Conversion for Physician Subacute Care Services page. Providers must not bill the new coding standards until they are instructed to do so in future Medi-Cal Updates.
The following changes are effective April 1, 2011:
Initial subacute care, per day, for the evaluation and management of a patient, which requires these three key components:
A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity Procedure Type N: $34.30
Procedure Type P: $30.60 99221 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity and
Procedure Type N: $34.30 Procedure Type P: $30.60 • Use modifier U2 to identify subacute level of care X9924
A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity Procedure Type N: $73.20
Procedure Type P: $65.20 99222 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity and
Procedure Type N: $73.20
Procedure Type P: $65.20 • Use modifier U2 to identify subacute level of care X9926
Initial subacute care, per day, for the evaluation and management of a patient, which requires these three key components:A comprehensive history; A comprehensive examination; and Medical decision making of high complexity
Procedure Type N: $80.10
Procedure Type P: $71.40 99223 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components:
Procedure Type N: $80.10 Procedure Type P: $71.40 • Use modifier U2 to identify subacute level of care X9928
Subsequent subacute care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused interval history;
A problem focused examination; and Medical decision making that is straightforward or of low complexity
Procedure Type N: $28.60 Procedure Type P: $25.50 99231 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:
Procedure Type N: $27.50 Procedure Type P: $24.50
• Use modifier U2 to identify subacute level of care X9930
Subsequent subacute care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused interval history;
Procedure Type N: $37.80 Procedure Type P: $33.60 99232 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:
Procedure Type N: $37.80 Procedure Type P: $33.60 • Use modifier U2 to identify subacute level of care X9932
Subsequent subacute care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A detailed interval history; A detailed examination; and Medical decision making of high complexity $45.80
99233 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components:<
A detailed interval history; A detailed examination; and Medical decision making of high complexity and
• Use modifier U2 to identify subacute level of care X9934
Subacute care discharge day management $22.90
99238 – Hospital discharge day management; 30 minutes or less 99239 – Hospital discharge day management; more than 30 minutes and
$53.40 • Use modifier U2 to identify subacute level of care X9936
Office consultation, for a new or established patient, which requires these three key components:
A problem focused examination; and Straightforward medical decision making
Procedure Type P: $30.60 99241 – Office consultation, for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state Procedure Type N: $30.60 Procedure Type P: $30.60 • Use modifier U2 to identify subacute level of care X9938
A expanded problem focused examination; and Straightforward medical decision making
Procedure Type P: $30.60 99242 – Office consultation, for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $47.20 Procedure Type P: $47.20 • Use modifier U2 to identify subacute level of care X9940
Office consultation, for a new or established patient, which requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity
Procedure Type N: $51.00
Procedure Type P: $51.00
99243 – Office consultation, for a new or established patient, which requires these three key components:
A detailed history; A detailed examination; and Medical decision making of low complexity
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $59.50 Procedure Type P: $59.50 • Use modifier U2 to identify subacute level of care X9942
Office consultation, for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity
99244 – Office consultation, for a new or established patient, which requires these three key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity
U2 – Medicaid Level of Care 2, as defined by each state	$81.40
• Use modifier U2 to identify subacute level of care X9944
A comprehensive history; A comprehensive examination; and Medical decision making of high complexity
99245 – Office consultation, for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state	$102.20
• Use modifier U2 to identify subacute level of care X9946
Initial subacute care consultation, for a new or established patient, that requires these three key components:
Procedure Type P: $30.60 99251 – Inpatient consultation for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $27.86 Procedure Type P: $27.86
• Use modifier U2 to identify subacute level of care X9948
Initial subacute care consultation, for a new or established patient, that requires these three key components: An expanded problem focused history;
Procedure Type P: $30.60 99252 – Inpatient consultation for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $33.46 Procedure Type P: $32.46
• Use modifier U2 to identify subacute level of care X9950
Initial subacute care consultation, for a new or established patient, that requires these three key components: A detailed history; A detailed examination; and Medical decision making of low complexity
99253 – Inpatient consultation for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $46.44 Procedure Type P: $46.44 • Use modifier U2 to identify subacute level of care X9952
A comprehensive history; A comprehensive examination; and Medical decision making of modeerate complexity
99254 – Inpatient consultation for a new or established patient, which requires these three key components:
A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity
U2 – Medicaid Level of Care 2, as defined by each state	$65.01
• Use modifier U2 to identify subacute level of care X9954
• Use modifier U2 to identify subacute level of care X9956
Follow-up subacute care consultation, for an established patient, that requires at least two of these three key components:
99231 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused history;
• Use modifier U2 to identify subacute level of care X9958
An expanded problem focused examination; and Medical decision making of moderate complexity
99232 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: An expanded problem focused history;
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $37.80 Procedure Type P: $33.60
• Use modifier U2 to identify subacute level of care X9960
Follow-up subacute care consultation, for an established patient, that requires at least two of these three key components: Detailed interval history; Detailed examination; and Medical decision making of high complexity
99233 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: Detailed interval history; Detailed examination; and Medical decision making of high complexity
U2 – Medicaid Level of Care 2, as defined by each state	$45.80
• Use modifier U2 to identify subacute level of care X9962
Confirmatory subacute care consultation, for a new or established patient, that requires these three key components:
99251 – Inpatient consultation for a new or established patient, which requires these three key components:
• Use modifier U2 to identify subacute level of care X9964
An expanded problem focused examination; and Straightforward medical decision making
99252 – Inpatient consultation for a new or established patient, which requires these three key components:
U2 – Medicaid Level of Care 2, as defined by each state Procedure Type N: $33.46 Procedure Type P: $32.46
• Use modifier U2 to identify subacute level of care X9966
A detailed examination; and Medical decision making of low complexity
99253 – Inpatient consultation for a new or established patient, which requires these three key components: A detailed history;
U2 – Medicaid Level of Care 2, as defined by each state	Procedure Type N: $46.44 Procedure Type P: $46.44 • Use modifier U2 to identify subacute level of care X9968
A comprehensive examination; and Medical decision making of moderate complexity
• Use modifier U2 to identify subacute level of care X9970
A comprehensive examination; and Medical decision making of high complexity
• Use modifier U2 to identify subacute level of care Note:
3. Modifiers of Anesthesia Services Code Conversion
Effective for dates of service on or after March 1, 2011, the Department of Health Care Services (DHCS) will discontinue the use of current local modifiers ZA, ZB, ZC, ZD, ZE, ZF, ZG, ZH, ZI, ZJ, ZO, ZP, ZR, ZT, ZX and ZY used with anesthesia services. These local modifiers will be replaced by HIPAA compliant HCPCS modifiers to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Section 162.1000. The proposed modifiers are now available for review and comments. The public forum begins on October 1, 2010 and will close at 5 p.m. on November 15, 2010. Providers can access the public forum by visiting the Public Comment Forum: Code Conversion for Modifiers of Anesthesia Services page. Providers must not bill the new coding standards until they are instructed to do so in future Medi-Cal Updates. The following changes are effective March 1, 2011:
Medi-Cal Modifer
Modifier Description Proposed National Modifier(s) ZA
Anesthesia procedures complicated by unusual position or surgical field avoidance 22 – Increased procedural services ZB
Anesthesia (emergency services, healthy patient) P1 – A normal healthy patient and ET – Emergency services ZC
Anesthesia complicated by extracorporeal circulation P4 – A patient with severe systemic disease that is a constant threat to life
Note:Use ICD-9-CM diagnosis code 998.89 (other specified complications of procedures, not otherwise classified) to indicate extracorporeal circulation.
Emergency anesthesia (systemic disease) P4 – A patient with severe systemic disease that is a constant threat to life and
ET – Emergency services ZE
Nurse anesthetist service; elective anesthesia: normal, healthy patient
P1 – A normal healthy patient and QX – CRNA service: with medical direction by a physician ZF
Anesthesia supervision QK – Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals
Note: Modifier QK will also be used when billing for the supervision of one anesthesia procedure.
Multiple anesthesia modifiers 99 – Multiple modifiers
Nurse anesthetist service; anesthesia special circumstances: unusual position/field avoidance 22 – Increased procedural services and QX – CRNA service: with medical direction by a physician ZI
Nurse anesthetist service; anesthesia special circumstances: total body hypothermia P4 – A patient with severe systemic disease that is a constant threat to life and QX – CRNA service: with medical direction by a physician
Note: Use ICD-9-CM code 995.89 (other specified adverse effects, not elsewhere classified) when billing for total body hypothermia.
Nurse anesthetist service; emergency anesthesia: normal, healthy patient
P1 – A normal healthy patient and QX – CRNA service: with medical direction by a physician and ET – Emergency services ZO
Nurse anesthetist service; anesthesia special circumstances: extracorporeal circulation P4 – A patient with severe systemic disease that is a constant threat to life and QX – CRNA service: with medical direction by a physician
Note: Use ICD-9-CM diagnosis code 998.89 (other specified complications of procedures, not elsewhere classified) to indicate extracorporeal circulation. ZP
Nurse anesthetist service; elective anesthesia: patient with severe systemic disease that is a constant threat to life P4 – A patient with severe systemic disease that is a constant threat to life and QX – CRNA service: with medical direction by a physician
Nurse anesthetist service; emergency anesthesia: patient with severe systemic disease that is a constant threat to life P4 – A patient with severe systemic disease that is a constant threat to life and
QX – CRNA service: with medical direction by a physician and ET – Emergency services ZT
Nurse anesthetist service; emergency anesthesia: moribund patient who is not expected to survive without the operation P5 – A moribund patient who is not expected to survive without the operation and QX – CRNA service: with medical direction by a physician and ET – Emergency services
Nurse anesthetist service; emergency or elective anesthesia: patient with severe systemic disease P3 – A patient with severe systemic disease and QX – CRNA service: with medical direction by a physician and
ET – Emergency services*
* ET can be billed to indicate emergency services if applicable
Note: When P3 + QX is billed with ET to indicate emergency anesthesia, an emergency certification is required
Nurse anesthetist service; elective anesthesia: moribund patient who is not expected to survive without the operation P5 – A moribund patient who is not expected to survive without the operation and QX – CRNA service: with medical direction by a physician and Print Article | Return to Top
4. Comprehensive Perinatal Services Program Billing Code Conversions
Effective for dates of service on or after April 1, 2011, the Department of Health Care Services (DHCS) will discontinue the use of current Medi-Cal interim codes for Comprehensive Perinatal Services Program (CPSP) services. These interim codes will be replaced by HIPAA-compliant codes and modifiers in order to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Part 162.1000.
The proposed national codes and modifiers were available for review and comments. The public forum began on November 1, 2010, and cosed at 5 p.m. on December 15, 2010. Providers must not bill the new coding standards until they are instructed to do so in future Medi-Cal Updates. The following changes are effective April 1, 2011: Interim Code Interim Code Description Interim Code Rate Proposed National Code/Modifier National Code Rate Billing Instructions ZL Initial comprehensive antepartum visit – within 16 weeks of LMP $56.63 HD – Pregnant/parenting women’s program $56.63 Use modifier HD to separately identify the antepartum visit as occurring within 16 weeks of the patient’s last menstrual period (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Z1032 Initial comprehensive pregnancy-related office visit $126.31 CPT-4 Code
TH – Obstetrical treatment/services, prenatal or postpartum
$126.31 When either 99205 or 99215 are billed with modifier TH. Z1036 Tenth and subsequent antepartum office visits $113.26 HCPCS Code
H1001 – Prenatal care, at-risk enhanced service; antepartum management
$113.26 Z6200 Z6202 Initial nutrition assessment and development of care plan; first 30 minutes
Initial nutrition assessment and development of care plan; each subsequent 15 minutes (maximum of 1½ hours) $16.83 $8.41 CPT-4 Code
97802 – Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Modifier
UA – Medicaid level of care 10, as defined by each state $8.41 per unit (maximum 8 per pregnancy) Use modifier UA to identify the service as antepartum. Z6204 Follow-up antepartum nutrition assessment, treatment and/or intervention; individual, each 15 minutes (maximum of 2 hours) $8.41 CPT-4 Code
97803 – Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Modifier
UA – Medicaid level of care 10, as defined by each state
$8.41 per unit (maximum 8 per pregnancy) Use modifier UA to identify the service as antepartum. Z6206 Follow-up antepartum nutrition assessment, treatment and/or intervention; group, per patient, each 15 minutes (maximum of 3 hours) $2.81 CPT-4 Code
97804 – Medical nutrition therapy; group (2 or more individuals), each 30 minutes
$5.62 per unit (maximum 6 per pregnancy) Use modifier UA to identify the service as antepartum.
Z6208 Postpartum nutrition assessment, treatment and/or intervention; including development of care plan, individual, each 15 minutes (maximum of 1 hour) $8.41 CPT-4 Code
97803 – Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Modifier UB – Medicaid level of care 11, as defined by each state $8.41 per unit (maximum 4 per pregnancy) Use modifier UB to identify the service as postpartum. Z6210 Prenatal vitamin-mineral supplement, 300-day supply (all 300 vitamins must be dispensed before they can be billed)
$30 HCPCS Code S0197 – Prenatal vitamins, 30-day supply $3 for 30-day supply Maximum units: 10 per day Z6300 Z6302 Initial psychosocial assessment and development of care plan; first 30 minutes|
Initial psychosocial assessment and development of care plan; each subsequent 15 minutes (maximum of 1½ hours) $16.83 $8.41 CPT-4 Code
96150 – Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment Modifier
UA – Medicaid level of care 10, as defined by each state $8.41 per unit (maximum 8 per pregnancy) Use modifier UA to identify the service as antepartum.
Z6304 Follow-up antepartum psychosocial assessment, treatment, and/or intervention; individual, each 15 minutes (maximum of 3 hours) $8.41 CPT-4 Code
96151 – Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment
Modifier UA – Medicaid level of care 10, as defined by each state
$8.41 per unit (maximum 12 per pregnancy) Use modifier UA to identify the service as antepartum.
Z6306 Follow-up antepartum psychosocial assessment, treatment and/or intervention, group, per patient, each 15 minutes (maximum of 4 hours) $2.81 CPT-4 Code
96153 – Health and behavior intervention, each 15 minutes, face-to-face; group
$2.81 per unit (maximum 16 per pregnancy) Use modifier UA to identify the service as antepartum. Z6308 Postpartum psychosocial assessment, treatment and/or intervention, including development of care plan, individual, each 15 minutes (maximum of 1½ hours) $8.41 CPT-4 Code
Modifier UB – Medicaid level of care 11, as defined by each state
$8.41 per unit (maximum 6 per pregnancy) Use modifier UB to identify the service as postpartum. Z6400 Client orientation (health education) each 15 minutes (maximum of 2 hours) $8.41 HCPCS Code
H1002 – Prenatal care, at-risk enhanced service; care coordination $8.41 per unit (maximum 8 per pregnancy) Z6402 Z6404 Initial health education assessment and development of care plan, first 30 minutes
Initial health education assessment and development of care plan, each subsequent 15 minutes (maximum of 2 hours) $16.83 $8.41 HCPCS Code
H1000 – Prenatal care; at-risk assessment $8.41 per unit (maximum 10 per pregnancy) Z6406 Follow-up antepartum health education assessment, treatment, and/or intervention, individual, each 15 minutes (maximum of 2 hours) $8.41 HCPCS Code
S9445 – Patient education, not otherwise classified, non-physician provider, individual, per session Modifier UA – Medicaid level of care 10, as defined by each state
$8.41 per unit (maximum 8 per pregnancy) Use modifier UA to identify the service as antepartum. Z6408 Follow-up antepartum health education assessment, treatment, and/or intervention, group, per patient, each 15 minutes (maximum of 2 hours) $2.81 HCPCS Code S9446 – Patient education, not otherwise classified, non-physician provider, group, per session
$2.81 per unit (maximum 8 per pregnancy) Use modifier UA to identify the service as antepartum. Z6410 Perinatal education, individual, each 15 minutes (maximum of 4 hours) $8.41 HCPCS Code
H1003 – Prenatal care, at-risk enhanced services; education
$8.41 per unit (maximum 16 per pregnancy) Z6412 Perinatal education, group, per patient, each 15 minutes (maximum of 16 units per day – 72 units per pregnancy) $2.81 HCPCS Code
HQ – Group setting
$2.81 per unit (maximum 16 per day, 72 per pregnancy) Z6414 Postpartum health education assessment, treatment and/or intervention, including development of care plan, individual, each 15 minutes (maximum of 1 hour) $8.41 HCPCS Code
$8.41 per unit (maximum 4 per pregnancy) Use modifier UB to identify the service as postpartum. Z6500 Initial comprehensive nutrition, psychosocial and health education assessments and development of care plan; first 30 minutes each assessment (total of 90 minutes), (includes ongoing coordination of care); the three assessments must be completed within 4 weeks of the “initial visit” (either the first pregnancy related visit or any one of the 3 initial assessments)
$135.83 HCPCS Code
H2000 – Comprehensive multidisciplinary evaluation
Modifier TH – Obstetrical treatment/services, prenatal or postpartum
$135.83 (maximum 1 per pregnancy) Print Article | Return to Top
5. Medical Abortion Billing Code Conversions
Effective for dates of service on or after April 1, 2011, the Department of Health Care Services (DHCS) will discontinue the use of current Medi-Cal interim code Z0336 for medical abortion services. This interim code will be replaced by HIPAA compliant HCPCS to comply with the provisions of HIPAA of 1996, Public Law 104-191, Code of Federal Regulations, Title 45, Part 162.1000.
The proposed national code were available for review and comments. The public forum began on November 1, 2010, and closed at 5 p.m. on December 15, 2010.
Providers must not bill the new coding standards until they are instructed to do so in future Medi-Cal Updates. The following change is effective April 1, 2011: Interim Code Interim Code Description Interim Code Rate Proposed National Code/Modifier National Code Rate Z0336 Medical Abortion $383.10 HCPCS Code
S0199 – Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion ) except drugs $383.10 Print Article | Return to Top
6. CDC Influenza Vaccine Recommendations
The Centers for Disease Control and Prevention (CDC) 2010 influenza vaccine recommendations include the following: Routine influenza vaccination is recommended for all persons aged 6 months and older, if not medically contraindicated. As in previous recommendations, all children aged 6 months through 8 years who receive a seasonal influenza vaccine for the first time should receive two doses. Children who received only one dose of a seasonal influenza vaccine in the first influenza season that they received vaccine should receive two doses, rather than one, in the following influenza season. In addition, for the 2010-2011 influenza season, children aged 6 months through 8 years who did not receive at least one dose of an influenza A (H1N1) 2009 monovalent vaccine should receive two doses of a 2010-2011 seasonal influenza vaccine, regardless of previous influenza vaccination history. Children aged 6 months through 8 years for whom the previous 2009-2010 seasonal or influenza A (H1N1) 2009 monovalent vaccine history cannot be determined should receive two doses of a 2010-2011 seasonal influenza vaccine. Minimal interval between two doses is four weeks. For more information about influenza vaccination recommendations, providers can review the Morbidity and Mortality Weekly Report (MMWR): Prevention and Control of Influenza with Vaccines on the CDC website. Print Article | Return to Top
7. Form Removed from the Provider Manual
Effective January 1, 2011, the Recombinant Human Erythropoietin (RhuEPO) Documentation Requirements form will be removed from the provider manual. Information from the form has been incorporated into the Injections: Drugs A-L Policy section of the provider manual. Print Article | Return to Top
8. Correction: Diagnosis Code Requirements for Obstetrical Ultrasounds
A recent change in policy incorrectly prevented reimbursement for obstetrical ultrasound CPT-4 codes 76801 – 76812, 76815 and 76817 when billed in conjunction with ICD-9-CM diagnosis codes 637 – 637.92 (unspecific abortions). Claims that were inappropriately denied should be resubmitted for reprocessing. The six-month billing timeline will be overridden for dates of service September 27, 2010 to January 1, 2011. Claims must be received by the Fiscal Intermediary no later than July 1, 2011. Print Article | Return to Top
9. BRCA Analysis for Breast and Ovarian Cancer Policy and Benefit Updates
Effective for dates of service on or after February 1, 2011, HCPCS code S3820 (complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer) will no longer be split-billable. Effective for dates of service on or after February 1, 2011, the following tests are added as benefits of the Medi-Cal program: Reflex BRCA Analysis. Reflex BRCA analysis is indicated for individuals with a negative test result in the three-mutation or single mutation BRCA analysis and who have met one or more criteria listed under the subheading “Breast and Ovarian Cancer Gene Sequence Analysis: HCPCS Code S3820” in the Pathology: Billing and Modifiers section of the appropriate Part 2 provider manual. Additional policy is as follows: Reflex BRCA analysis may be billed using HCPCS code S3820 and modifier QP. A separate Treatment Authorization Request (TAR) is required for reflex BRCA analysis. It is a once-in-a-lifetime procedure. Single Mutation BRCA Analysis. This test is indicated for individuals with a family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA mutation. Additional policy is as follows: This test is billed using HCPCS code S3822 (single mutation analysis in individuals with a known BRCA1 or BRCA2 mutation in the family for susceptibility to breast and ovarian cancer). A TAR is required. It is a once-in-a-lifetime procedure. Three-Mutation BRCA1 and BRCA2 Analysis. This test is indicated for when an individual is of an ethnicity associated with the Ashkenazi Jewish population, and no additional family history may be required. Additional policy is as follows: This test is billed using HCPCS code S3823 (three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer in Ashkenazi individuals). A TAR is required. It is a once-in-a-lifetime procedure. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
hcpcs ii (6); modif app (7); once (1); path bil (16)
hcpcs ii (6); modif app (7); path bil (16)
modif app (7)
10. GHPP Claims Now Submitted to DHCS Fiscal Intermediary
Effective for dates of service on or after January 24, 2011, claims for services authorized with a Service Authorization Request (SAR) number beginning with “99” and rendered to Genetically Handicapped Persons Program (GHPP) clients are submitted to the Department of Health Care Services (DHCS) Fiscal Intermediary (FI). Claims for services that were previously authorized without a SAR number beginning with “99” must be submitted to GHPP for approval. GHPP is automating claims processing to expedite reimbursement. GHPP-authorized services with a SAR number beginning with “99” will be on a service authorization file at the FI, enabling providers to directly submit claims either electronically or hard copy. Authorization SARs will continue to be submitted to the GHPP state office. For authorization of services, providers’ SARs must contain the appropriate procedure code or Service Code Grouping (SCG). Note: An SCG is a group of reimbursable codes authorized to a provider under one SAR for the care of a GHPP client. SCGs used by GHPP are the same as SCGs used by California Children’s Services (CCS). SCGs and the lists of CPT-4 and HCPCS codes included in each Service Code Group are located in the Part 2 provider manual section, California Children’s Services (CCS) Program Service Code Groupings. After the GHPP state office reviews the SAR, an approval or denial is returned to the provider in hard copy format. The SAR will identify the provider’s unique SAR number beginning with the digits “99.” Additional SAR information is included in the newly updated Genetically Handicapped Persons Program (GHPP) provider manual section. Claim Completion Claims submitted for reimbursement must include the approved SAR number in the appropriate Treatment Authorization Request (TAR) field. Claims submitted without the SAR number will be denied. Claims for GHPP clients are completed in a similar manner to claims for CCS clients. GHPP providers needing help to complete claims may refer to the following provider manual sections: California Children’s Services (CCS) Program Billing Example: CMS-1500
California Children’s Services (CCS) Program Billing Example: CMS-1500 for Vision Care
California Children’s Services (CCS) Program Billing Example: Pharmacy Claim Forms
California Children’s Services (CCS) Program Billing Example: UB-04 Claim Form
This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Audiology and Hearing Aids
General Medicine Inpatient Services Local Educational Agency Medical Transportation Obstetrics Orthotics and Prosthetics Pharmacy Psychological Services Rehabilitation Clinics Therapies Vision Care
genetic (1, 3–11)
11. Trastuzumab Policy Update
Effective for dates of service on or after February 1, 2011, Trastuzumab may be used to treat malignant neoplasms of the stomach. HCPCS code J9355 (injection, trastuzumab, 10 mg) must be billed in conjunction with ICD-9-CM codes 151.0 – 151.9 (malignant neoplasm of the stomach) for the treatment to be reimbursable. Increased dosage may be administered with documentation indicating that the patient’s weight is greater than 137.5 kg (302 lbs). This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
General Medicine chemo drug p-z (11)
The following codes will be added/end-dated to/from the California Children’s Services (CCS) Service Code Groupings (SCGs): Added Code(s) Effective Date Code SCGs January 1, 2011 HCPCS codes J0285, J0287 – J0289 01, 02, 03, 07 and 12 January 1, 2011 HCPCS codes J3301, J3303, and J9185 01, 02, 03 and 07 End-Dated Code(s) Effective Date Code SCGs January 1, 2011 HCPCS code X5572 01, 02, 03, 07 and 12 January 1, 2011 HCPCS codes X5552, X5880 and X7644 01, 02, 03 and 07 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 This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Audiology and Hearing Aids
Clinics and Hospitals Durable Medical Equipment and Medical Supplies General Medicine Home Health Agencies/Home and Community-Based Services
Inpatient Services Local Educational Agency Medical Transportation
Pharmacy Psychological Services Rehabilitation Clinics Therapies Vision Care cal child ser (1–2, 4, 24)
13. Glucagon Code Conversion
Effective for dates of service on or after February 1, 2011, local HCPCS codes X6252 (glucagon, 10 mg/ml) and X6254 (glucagon, 1 mg/ml) will be converted to national HCPCS code J1610 (injection, glucagon hydrochloride, per 1 mg). This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
14. Parathormone Billing Limitations
Effective for dates of service on or after February 1, 2011, reimbursement for parathormone (parathyroid hormone, CPT-4 code 83970) is limited to one unit of service per day, same recipient, same date of service for all laboratory providers. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Chronic Dialysis Clinics
path chem (8)
15. Payments During Demonstration Project Extension
Since September 2005, California has operated the Medi-Cal Hospital/Uninsured Care Demonstration (Waiver 11-W-00193/9) Project (the Demonstration Project) in accordance with the special terms and conditions (STCs) agreed to by the federal Centers for Medicare & Medicaid Services (CMS) and the state, and in accordance with the statutory provisions contained in the Medi-Cal Hospital/Uninsured Care Demonstration Project Act (the Act) Welfare & Institutions Code (W&I Code), Sections 14166 – 14166.26. As originally approved, the Demonstration Project was authorized through August 31, 2010. The Department of Health Care Services (DHCS) and CMS have developed a successor demonstration project which was approved by CMS with an effective date of November 1, 2010. As part of this process, DHCS has received approval from CMS for an extension of the previous Demonstration Project effective September 1 through October 31, 2010. As a result, the list of expenditure authorities and STCs in place as of August 31, 2010 continue to apply to the Demonstration Project until October 31, 2010. Pursuant to W&I Code, Sections 14166.252 and 14166.2(h), DHCS is authorized to implement and administer the Demonstration Project by means of provider bulletins. This provider bulletin sets forth changes to payment methods that DHCS will apply in operating the Demonstration Project during the extension period. The policies announced in this bulletin are intended to preserve the payment methodologies that have been utilized in connection with the Demonstration Project, with such adjustments as are necessary to take into account the extension granted by CMS. During the extension period DHCS will continue to make payments to providers, including interim payments, in accordance with the Act, consistent with this bulletin and consistent with the STCs amended February 1, 2010. All provisions of W&I Code, Sections 14166 – 14166.26 that are not in direct conflict with the payment methodologies announced in this bulletin shall continue to be applicable during the extension period. Definitions
The following definitions apply for purposes of this bulletin: “Extension period” means the period that begins on September 1, 2010, and ends on October 31, 2010, which is the temporary extension period approved by CMS. “Extended calculation period” means the period that begins on July 1, 2010 and ends on October 31, 2010, which includes both the extension period and the preceding months of the state fiscal year. “Extension percentage” means 33⅓ percent, which is the percentage obtained by dividing the four months in the extended calculation period by 12 months. For the purposes of making payments to hospitals for the extended calculation period as described in this bulletin, the term “project year”, as defined in W&I Code, Sections 14166.1(g), refers to the four month extended calculation period and not to the entire state fiscal year. Changes to Demonstration Project Payment Methodologies
Changes Applicable to Designated Public Hospitals
Designated public hospitals listed in W&I Code, Sections 14166.1(d) except for Tuolumne General Hospital and Los Angeles County Martin Luther King Jr. – Harbor Hospital will continue to receive the payments described in W&I Code, Sections 14166.35 for the extended calculation period, subject to the adjustments contained in this bulletin.
The adjusted baseline for each designated public hospital will be calculated for the extended calculation period by multiplying the adjusted baseline calculated for the designated public hospital for state fiscal year 2010-2011 using the methodology in W&I Code, Sections 14166.5 by the extension percentage. Fee-for-service payments to designated public hospitals for inpatient services and supplemental reimbursement for costs incurred for physician and nonphysician practitioner services during the extended calculation period will continue to be provided pursuant to W&I Code, Sections 14166.4 and the applicable Medi-Cal State Plan amendments.
Stabilization funds will be allocated to designated public hospitals for the extended calculation period in the same manner they were allocated for state fiscal year 2009-10, as described in W&I Code, Sections 14166.75, except that: DHCS will multiply the dollar amounts contained in subdivisions (b) and (c) by the extension percentage; For the purpose of paragraph (e)(2), the allowable costs for the previous year will be multiplied by the extension percentage, to allow an appropriate comparison with the extended calculation period. The certified public expenditures and associated federal financial participation for services provided during the extended calculation period will be used for purposes of the determinations in paragraph (e)(3). Designated public hospitals will not be required to submit reports pursuant to W&I Code, Sections 14166.8 until 5 months after the end of the 2010-2011 state fiscal year. The reports required under W&I Code, Sections 14166.8 will reflect costs incurred during the full state fiscal year. Changes Applicable to Private Hospitals
During the extended calculation period, private hospitals as defined in W&I Code, Section 14166.1(j) will continue to receive the payments described in W&I Code, Section 14166.10, subject to the adjustments contained in this bulletin and W&I Code, Section 14105.281.
For the extended calculation period, the aggregate project year private Disproportionate Share Hospitals (DSHs) adjusted baseline funding amount shall be calculated using the methodology in W&I Code, Section 14166.13, multiplying the result by the extension percentage. The California Medical Assistance Commission will continue to negotiate supplemental payment amounts from the Private Hospital Supplemental Fund for the extended calculation period. The payments will be negotiated in accordance with W&I Code, Section 14166.12 in the same manner as if that section were operative for the entire 2010 – 2011 state fiscal year. The amount identified in W&I Code, Section 14166.12(d)(1) that would be payable for the entire 2010 – 2011 state fiscal year will be multiplied by the extension percentage to derive the amount of private hospital supplemental payments that relates to the extended calculation period. DHCS will continue to pay project year private DSH replacement payments to private DSHs during the extended calculation period in accordance with W&I Code, Section 14166.11 and in the same manner as DHCS would implement that section were it operative for the entire 2010-2011 state fiscal year. The amount of DSH replacement payments that would be payable for the entire 2010-2011 state fiscal year will be multiplied by the extension percentage to calculate the payments that relate to the extended calculation period.
Changes Applicable to Nondesignated Public Hospitals
Nondesignated public hospitals as defined in W&I Code, Section 14166.1(f) will continue to receive the payments described in W&I Code, Section 14166.15 for the extended calculation period, subject to the adjustments contained in this bulletin and W&I Code, Section 14105.281. The aggregate nondesignated public hospital adjusted baseline funding amount for the extended calculation period shall be calculated by using the methodology in W&I Code, Section 14166.18, multiplying the result by the extension percentage. The California Medical Assistance Commission will continue to negotiate supplemental payment amounts from the Nondesignated Public Hospital Supplemental Fund for the extended calculation period. The payments will be negotiated in accordance with W&I Code, Section 14166.17 in the same manner as if that section were operative for the entire 2010 – 2011 state fiscal year. The amount identified in W&I Code, Section 14166.17(d)(1) that would be payable for the entire 2010 – 2011 state fiscal year will be multiplied by the extension percentage to derive the amount of nondesignated public hospital supplemental payments that relates to the extended calculation period. Stabilization State General funding will be transferred to the Nondesignated Public Hospital Supplemental Fund as may be required by W&I Code, Section 14166.19, except that the factor $1.9 million in subdivision (a) will be multiplied by the extension percentage. Changes to Disproportionate Share Hospital Payments
DSH payments will continue to be allocated and paid as provided in W&I Code, Sections 14166.3, 14166.6, and 14166.16. The federal disproportionate share allotment specified for California for federal fiscal year 2010 – 2011 will be multiplied by the extension percentage to determine the amount of DSH payments allocable to the extended calculation period. Changes Regarding Safety Net Care Pool Funds
Additional Safety Net Care Pool (SNCP) funds are available at $255 million (total computable), which represents a two-month prorated share of the prior $1.532 billion (total computable) annual allotment for the extension period. The additional SNCP funds, excluding any amounts that are or were available for the health care coverage initiative program, will be distributed as follows:
The additional SNCP funds will be deposited in the Health Care Support Fund and distributed in accordance with the W&I Code, Section 14166.21, except that the amount of federal financial participation paid to the state as SNCP funds that are based on federal medical assistance percentage (FMAP) increases under the federal American Recovery and Reinvestment Act (Public Law 111-5), as amended by federal Public Law 111-226, will be deposited in the Federal Trust Fund and expended in accordance with W&I Code, Section 14166.221(d). A portion of the additional SNCP funds will be transferred to the South Los Angeles Medical Services Preservation Fund in accordance with W&I Code, Section 14166.25. The amount transferred will be $16.667 million, which represents a two-month prorated share of the $100 million authorized by W&I Code, Section 14166.25(c). Changes Regarding Stabilization Amounts Stabilization funds for the extended calculation period will be determined in accordance with W&I Code, Section 14166.20, except: For purposes of subdivision (a), in determining the amount of funds in excess of the amount necessary to meet baseline funding amounts for private disproportionate share hospitals and nondesignated public hospitals, the payment amounts that relate to the extended calculation period as determined in W&I Code, Sections 14166.11, 14166.12 and 14166.17 will be taken into account regardless of when such payments were made; and Each amount specified in paragraphs (b)(1), (b)(2), and (b)(3) will be multiplied by the extension percentage. Health Care Coverage Initiative
Under the extension period, DHCS will continue to administer the existing Health Care Coverage Initiative programs approved under Part 3.5 of Division 9 of the W&I Code, Section 15900, et seq. DHCS will allocate the additional federal funds, which represent a two-month prorated share of each existing program’s annual allocation (made pursuant to W&I Code, Section 15904(f)).
16. Adenosine Code Conversion
Effective for dates of service on or after February 1, 2011, l ocal code X5522 (adenocrest, 25 mg/m) will be terminated and converted to national HCPCS code J0150 (injection, adenosine for therapeutic use, 6 mg) and code J0152 (injection, adenosine for diagnostic use, 30 mg). Claims billed using code X5522 on or after February 1, 2011 will be denied. Deleted Code Replacement Code(s) X5522 J0150, J0152 This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Chronic Dialysis Clinics
Rehabilitation Clinics inject cd list (2, 5)
17. Effective Implementation of ICD-10: Part II –Navigating Issues
A successful implementation of the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) by October 1, 2013 requires planning. Key components of this planning are to identify potential issues and develop effective strategies to alleviate any problems that occur during the transition to the new code sets. While organizations may face their own unique issues, here are some guidelines for the more general ones which will assist in planning and implementation. Potential Business Issues –The transition to ICD-10 will heavily impact business processes, policies and functions. The ICD-9 Clinical Modifications (CM) has been in use for more than 30 years and is interwoven into every aspect of health care. Policies and processes that may be routine today could be dramatically impacted as a consequence of the transition to ICD-10. Following are some potential issues to consider and some tips for navigating them: Adequate resources – The ICD-10 transition is not a one-person job. A diverse set of skills, knowledge and experience is necessary for a successful implementation. Assessments of staffing levels, knowledge and capabilities can help prepare for both immediate and future needs. Budgets – A managed budget is critical. The size and variables associated with this transition will require changes to budgets as information unfolds during the assessment. Arranging for contingencies, along with funding reserves, can be helpful in managing the financial impact of the transition. Communications – ICD-10 affects all aspects of health care. Each organization must manage the transition according to its business needs and functions. Since there is no one-size-fits-all solution, it is vital to maintain frequent and consistent communication between providers, health plans and vendors. This way, difficulties that may arise can be remedied sooner rather than later. Potential Technical Issues – Similar to the above ramifications on business processes and policies, moving to ICD-10 will have a significant impact on information systems and technical infrastructure. Changing of the existing information and claims systems based on ICD-9-CM will require analysis of their current uses in the development of solutions to accommodate ICD-10. The following are some possible issues, plus tips for handling these steps: System constraints – Not all information systems are created equally, and some are older than others. Determining whether a system can accommodate the upgrades necessary for ICD-10 should be done early in order to provide solutions and develop contingencies. Translation – In some instances an organization may choose to translate from ICD-9-CM to ICD-10 Clinical Modifications and Procedure Code Systems (CM/PCS). To assist in this effort, the Centers for Medicare & Medicaid Services (CMS) developed the General Equivalence Mappings (GEM). However, any use of GEMs for mapping between ICD-9 and ICD-10 should be reviewed carefully to avoid unintended results. Providers should take into account that ICD-10 is a new code set and in the majority of instances only approximately maps to ICD-9. As a rule, services should not be coded using the GEMs. Vendor readiness – It is in the best interest of vendors to be prepared for ICD-10, though they may differ in their approaches. Therefore, early communication with vendors is essential. It is imperative that vendors provide a detailed work-up, including a suite of products that will ensure compliance with ICD-10 by the 2013 deadline. This requires the capability to perform internal and external testing. Monitoring Progress and Post-Compliance Date Actions – Continued awareness of the transition to ICD-10, both internally and externally, is necessary to identify issues during and after the transition. While monitoring the progress of the transition within an organization is a key activity, there are also issues that may crop up after implementation that will need to be addressed in order to realize the benefits of ICD-10. Here are some actions to keep in mind for current and post-implementation business operations: Timelines – Monitoring timelines is an important function while tracking the progress of the transition. Even though on occasion they may need to be adjusted due to unforeseen circumstances, timelines ensure that the desired scope of activities is being completed on a schedule to meet the necessary deadline. Post-compliance review – There’s so much to do leading up to the compliance date that sometimes the needed activities of measuring the implementation plan’s success are put aside. The success of ICD-10 rests chiefly on how the information is reported and how it is used. If there are no preparations to evaluate the output of ICD-10, then the measure of success is lost. Early planning will ensure that problems encountered are manageable. Members of affected organizations should start dialoguing now about transitioning to ICD-10. For more information providers may visit: Provider resources for the ICD-10 at the CMS website. Preparing for ICD-10 at the AHIMA website. General information at the WEDI website. Print Article | Return to Top
18. Romiplostim Dosage Adjustment
Effective retroactively for dates of service on or after September 1, 2010, the maximum dose for HCPCS code J2796 (injection, romiplostim, 10 micrograms) is adjusted to 10 mcg/kg weekly or 1000 mcg/week. When billing for a quantity greater than 1000 mcg, providers must document that the patient’s weight exceeds 100 kg. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
General Medicine chemo drug p-z (7–8)
19. Provider Orientation and Update Sessions
February 17, 2011 8:30 a.m. – 4 p.m. Hotel Mar Monte 1111 East Cabrillo Boulevard Santa Barbara, CA 93103 (805) 963-0744 Ontario
May 12, 2011 8:30 a.m. – 4 p.m. Hilton Ontario Airport 700 North Haven Avenue Ontario, CA 91764 (909) 980-0400 Mendocino June 9, 2011 8:30 a.m. – 4 p.m. The Stanford Inn 44855 Comptche Ukiah Road
Mendocino, CA 95460 1-800-331-8884 For a map and directions to these locations, providers can go to the Family PACT website and click “Directions and Map of Location” for the appropriate session location.
The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows. Addition, effective October 19, 2010
NDC Labeler Code Contracting Company’s Name 49702 VIIV HEALTHCARE Additions, effective January 1, 2011 NDC Labeler Code Contracting Company’s Name 42847 SOMAXON PHARMACEUTICALS, INC. 49769 KYLEMORE PHARMACEUTICALS LLC Additions, effective April 1, 2011 NDC Labeler Code Contracting Company’s Name 23360 AKORN STRIDES 27808 TRIS PHARMA, INC. 51477 NESHER PHARMACEUTICALS, INC. Reinstated, effective January 1, 2011 NDC Labeler Code Contracting Company’s Name 11994 LANTHEUS MEDICAL IMAGING, INC. Terminations, effective April 1, 2011
NDC Labeler Code Contracting Company’s Name 15210 ONCOLOGY THERAPEUTICS NETWORK JOINT VENTURE 52769 AMERICAN RED CROSS 59767 DIGESTIVE CARE, INC. 63672 SYNTHON PHARMACEUTICALS, INC. 64019 CEBERT PHARMACEUTICALS, INC. 64597 AVANIR PHARMACEUTICALS, INC. 64894 GENZYME CORPORATION 68322 AVANIR PHARMACEUTICALS, INC. Voluntary termination, effective April 1, 2011
NDC Labeler Code Contracting Company’s Name 58790 ADVANCED VISION RESEARCH This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Pharmacy drugs cdl p5 (6–11, 13–14, 16)
21. Medical Supply Products: Contracted Incontinence Creams and Washes Update The Department of Health Care Services (DHCS) recently renewed contracts with manufacturers for incontinence creams and washes. The renewed contracts include Universal Product Number (UPN) updates and deletion of products. The new UPNs will be effective for dates of service on or after February 1, 2011; deletions of products or UPNs will be effective for dates of service on or after April 1, 2011. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
incont con (1)
incont con (1); incont prod cr (1–10)
22. E&M Observation Codes No Longer Reimbursable
Effective for dates of service on or after February 1, 2011, Medi-Cal will no longer reimburse Evaluation and Management (E&M) codes billed as “observation status.” When providers write an order to “admit to observation status,” Medi-Cal will consider it to be the same as “admit to inpatient status.” The following observation codes are no longer payable: CPT-4 Code Description 99217 Observation care discharge 99218 – 99220 Initial observation care 99234 – 99236 Observation or inpatient hospital care Providers should instead bill using the following inpatient E&M codes: CPT-4 Code Description 99221 – 99223 Initial hospital care 99231 – 99233 Subsequent hospital care 99238, 99239 Hospital discharge day management This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
eval (8–11); modif used (3, 10); non ph (8, 18); radi onc (1); rates max (5); respir (8)
Rehabilitation Clinics modif used (3, 10); non ph (8, 18); respir (8)
modif used (3, 10)
respir (8)
23. No Documentation Required for Resuscitation Code Billed with NICU Codes
Effective retroactively for dates of service on or after January 16, 2008, CPT-4 code 99465 (delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output), may be reimbursed when billed the same day as Neonatal Intensive Care Unit (NICU) codes Z0100 – Z0108. Claims billed with code 99465 will automatically be reprocessed. Providers do not have to bill again and no documentation will be required to justify payment. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals General Medicine Obstetrics eval (15–16)
24. Update: Medi-Cal Implementation of National Correct Coding Initiative
Medi-Cal is progressing toward the implementation of the National Correct Coding Initiative (NCCI) payment methodologies. The NCCI is a national standard for the accurate and consistent description of medical goods and services using procedural codes. After the implementation of the NCCI edits for Medi-Cal services, new claims will be adjudicated based on dates of service on or after October 1, 2010. Providers should review the December Medi-Cal Update for more information on what this mandate means for Medi-Cal. For more information on the federal mandate, providers should visit the NCCI Edits Overview page on the Centers for Medicare & Medicaid Services (CMS) website. Print Article | Return to Top
25. Pertussis Vaccine Recommendations Background
History Pertussis, more commonly known as whooping cough, is caused by the bacterium Bordetella pertussis and is a highly contagious respiratory tract infection. Prior to the availability of the vaccine in the 1940s, pertussis was a leading cause of childhood illness and mortality in the United States (U.S.) and worldwide.1,2 Following large-scale vaccination in the 1950s and 1960s, the incidence and mortality from pertussis decreased dramatically by more than 80 percent in the U.S.1and 90 percent in the industrialized world.2 Despite the success of the vaccine, there was a resurgence of the disease in the 1990s, with a shift in prevalence toward older persons whose immunity from childhood vaccination have waned.3 Pertussis remains common and is a public health concern not only in the U.S., but also worldwide.2 Current Situation California is currently experiencing a pertussis epidemic.4 As of November 2, 2010, 6,431 pertussis cases have been reported in California this year alone, the most since 1950 when 6,613 cases were reported.5 The epidemic is taking its heaviest toll on the infant population, who are too young to be fully immunized and therefore remain vulnerable to infection.5 Pertussis is most severe in infants younger than 1 year of age; with the risk of death being highest among those less than 6 months old.6 Seventy-five percent of hospitalized cases in California were infants younger than 6 months old and all ten reported deaths were infants 2 months of age or younger.5 Pertussis is a vaccine-preventable disease. However, immunization rates for adolescents and adults are low.4 Unvaccinated individuals not only put themselves at risk for severe complications from pertussis, but can also spread the disease to young infants and children who are too young to be fully immunized, or others who may have contraindications to the vaccine. Approximately 75 percent of pertussis cases among infants 6 months of age or younger had a household contact (for example, parent, sibling) identified as the source of infection.6 It is therefore just as important for adolescents and adults, as it is for infants, to be immunized, in order to reduce the burden of pertussis on themselves and to prevent transmission of pertussis to others.6 During the current epidemic, when the risk of contracting pertussis is elevated, it is especially important that the community’s awareness about pertussis is heightened and that everyone who isn’t up-to-date on their vaccinations do so as soon as possible. A high level of community immunity will decrease the probability that susceptible individuals will come into contact with an infectious individual. This article outlines the recommendations for vaccination against pertussis in order to effectively control the spread of this preventable disease.
ROUTINE PERTUSSIS VACCINE RECOMMENDATIONS Infants and Children 6 Years of Age and Younger It is routinely recommended that infants and children receive five doses of DTaP (pediatric formulation of acellular pertussis [aP] vaccine combined with tetanus [T] and diphtheria [D] toxoids), at 2, 4, 6 months, 15 through 18 months, and at 4 through 6 years of age.1
Table 1 lists the recommended age, minimum age and minimum time interval for each dose of the DTaP vaccine series: Table 1: Recommended Age and Intervals for DTaP Doses 1 Vaccine Dose Recommended Age Minimum Age Minimum Interval 1 2 Months 6 Weeks --- 2 4 Months --- 4 Weeks 3 6 Months --- 4 Weeks 4 †
15 – 18 Months 12 Months 6 Months 5 ‡ (Booster) 4 – 6 Years 4 Years --- † Dose may be given earlier than recommended if it is unlikely the patient will return at 15 – 18 months and if the minimum age and interval are met.1 ‡ Dose not necessary if the fourth dose was given on or after the 4th birthday, but may still be given.1 DTaP vaccines currently available in the U.S. and approved for use in infants and children 6 weeks through 6 years of age are:1 Tripedia, Infanrix, and Daptacel. DTaP is also available in combination with other vaccines routinely administered during infancy (for example, Pediarix [DTaP – Hep B – IPV]).1 As children get older, immunity to pertussis by vaccine deteriorates, leaving them vulnerable to infection again by adolescence.4 In 2005, Tdap, a booster vaccine formulated for adolescents and adults, containing acellular pertussis (ap) combined with tetanus (T) and diphtheria (d) toxoids, became available.7 Table 2 lists the two available brands of Tdap vaccines: Table 2: Available Brands of Tdap Vaccine1
Brand Approved Age Group Boostrix 10 through 64 years Adacel 11 through 64 years Broadened Vaccine Recommendations – In response tothe pertussis epidemic in California, the California Department of Public Health (CDPH) has broadened the vaccine recommendations to include the following underlined recommendations:4
Children 7 – 9 Years of Age The CDPH recommends children 7 – 9 years of age receive a dose of Tdap if they: Have an indication for vaccination against tetanus, diphtheria, or pertussis (for example, wound management), instead of Td (tetanus and diphtheria toxoids) or TT (tetanus toxoid) vaccines.7 Did not complete their childhood DTaP vaccine series4 Note:
No pertussis-containing vaccines are currently licensed for use in children age 7 - 9 years of age. Adolescents and Adults Age 10+ The CDPH recommends any adolescent or adult 10 years of age or older, including those 65 years of age and older, whom have not received a documented dose of Tdap, should receive one, regardless of the time elapsed since their last Td booster.4
No pertussis-containing vaccines are currently licensed for use in adults 65 years of age and older. Adolescents who completed their childhood pertussis vaccine series are routinely recommended to receive a dose of Tdap preferably at 11 to 12 years of age.8
Adolescents 13 – 18 years of age who missed getting Tdap at 11 – 12 years of age, should receive a dose at their next doctor visit, or sooner if close contact with infants is anticipated.8
The Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind is available for adolescents who did not complete their childhood vaccine series.8
Adults 19 – 64 years of age whom have not received a dose of Tdap are recommended to get one.8 Pregnant/Postpartum Women Ideally, Tdap should be received before pregnancy.8
Postpartum women who have not received Tdap should receive a dose in the immediate postpartum period, before discharge from the hospital or birthing center, or as soon as feasible.8
Pregnancy is not a contraindication for receiving Tdap.8
Pre-licensure studies for Tdap did not include pregnant women; therefore, the safety of Tdap in this population is not well understood.6
During a community outbreak when the risk of contracting pertussis is elevated, healthcare providers may consider administering Tdap to pregnant women, but should weigh the risks and benefits before choosing to do so.8
Close Contacts of Infants All close contacts of infants should be immunized with Tdap, especially parents or other family members, and caregivers, before mother and child are discharged from the hospital; ideally at least one month prior to the anticipated close contact with the infant.7,1
Healthcare Personnel All healthcare personnel are recommended to be immunized with Tdap, particularly those who have direct contact with infants and pregnant women.7 CONTRAINDICATIONS
DTaP and/or Tdap are contraindicated in individuals with a history of:
Anaphylaxis following a prior dose of DTaP or Tdap.1 Encephalopathy occurring within 7 days of DTaP or Tdap administration without any other identifiable cause.1
AVOIDING CONFUSION BETWEEN DAPTACEL AND ADACEL Mix-ups have occurred between Daptacel (DTaP), formulated for infants and children 6 weeks to 6 years of age, and Adacel (Tdap), approved for use in adolescents and adults 11 through 64 years of age.9 The Institute for Safe Medication Practices (ISMP) reported that 20 adults from two different clinics received Daptacel in error instead of Adacel, as intended.9 Similarities in brand name, generic designations, vaccine abbreviations, and packaging are believed to have contributed to the confusion.9 To help prevent mix-ups between the two products, ISMP recommends the following: Separate and place alerts on the stock of the two formulations.9 Place alerts on computer software to warn about the differences between the two formulations and configure the system to prevent selection of the wrong product based on patient age.9 Verify patient age before dispensing or administration of vaccines.9
Share the Adacel (Tdap) and Daptacel (DTaP) Confusion article from the ISMP August 24, 2006 issue with your professional colleagues.9 DISCUSSION Vaccines have played a critical role in improving public health by preventing and controlling many infectious diseases that were once common in the U.S., including pertussis. Until a disease is completely eradicated, it is important to continue immunizing against it. Unfortunately, immunization rates for the recommended pertussis booster vaccine, Tdap, have been low.4 A recent Centers for Disease Control and Prevention (CDC) survey indicates that only 44 percent of adolescents in California and 6 percent of adults nationwide, have received Tdap.4 In order to reduce the incidence of pertussis, a high level of community immunity is needed.7 This can only be accomplished through widespread vaccination against pertussis, which will prevent exposure to vulnerable infants as well as prevent severe cases in older individuals.7
ANSWERS TO FREQUENTLY ASKED QUESTIONS The use of vaccines beyond licensed age groups is permitted by law.7 As the risk of contracting pertussis is heightened, an interval less than the recommended 5 years between Td and Tdap may be considered.7
The Tdap dose replaces one 10-year booster dose of Td.8
Interruption or delay in the vaccine schedule does not affect the level of immunity reached upon completion of the primary series; therefore, the series does not need to be restarted regardless of the time elapsed between doses.1 Children who started their vaccination series with DTP (whole-cell pertussis-containing vaccine no longer available in the U.S.) should complete it with DTaP.1 The same pertussis vaccine brand should be used to complete the series when possible. 1 However, vaccination should never be delayed due to unavailability of the same vaccine brand or if the brand previously used is unknown.1
Children who are moderately to severely ill should have their vaccinations deferred only until the condition improves.1 Mild illness (for example, upper respiratory tract infection) is not a reason for vaccine deferral.1 For additional information and resources on pertussis for healthcare providers and patients, please visit the CDPH and CDC websites. REFERENCES Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases textbook chapter on Pertussis. http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf. Accessed October 5, 2010. World Health Organization. Pertussis Vaccines: WHO Position Paper. Weekly Epidemiological Record. October 1, 2010. No.40, 2010, 85:385 – 400. http://www.who.int/wer/2010/wer8540.pdf. Accessed November 18, 2010. Mooi FR, van Loo IHM, van Gent M, et al. Emerging Infectious Diseases. 15; 8. August 2009. http://www.cdc.gov/eid/content/15/8/pdfs/1206.pdf. Accessed November 17, 2010. California Department of Public Health. Pertussis alert letter to general acute care hospitals. http://cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-10-24.pdf. Accessed September 14, 2010. California Department of Public Health. Pertussis Report: November 2, 2010. http://cdph.ca.gov/programs/immunize/Documents/PertussisReport2010-11-02.pdf. Accessed November 8, 2010. Centers for Disease Control and Prevention. Prevention of Pertussis, Tetanus, and Diphtheria Among Pregnant and Postpartum Women and Their Infants. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR May30, 2008; 57(04):1-47, 51. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5704a1.htm. Accessed September 14, 2010. California Department of Public Health. Pertussis Vaccination Recommendations 2010. http://eziz.org/PDF/CDPH%20Pertussis%20Immunization%20Policy%20July%202010.pdf
Centers for Disease Control and Prevention. Pertussis: Summary of Vaccine Recommendations. http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm
Institute for Safe Medication Practices. Adacel (Tdap) and Daptacel (DTaP) Confusion. August 24, 2006. http://www.ismedi-calmp.org/Newsletters/acutecare/articles/20060824_2.asp. Accessed December 8, 2010. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Drug Use Review Manual
36-96–36-100
26. Fulvestrant Code Updates
Effective for dates of service on or after February 1, 2011, local HCPCS code X7654 (fulvestrant, injection 250 mg) will be converted to national HCPCS code J9395 (injection, fulvestrant, 25 mg). Code J9395 must be billed with ICD-9-CM codes 174.0 – 174.9 (malignant neoplasm of female breast). The recommended dose of fulvestrant is 250 mg, administered intramuscularly into each buttock (for a total dose of 500 mg), on days 1, 15, 29 and once monthly thereafter. For patients with moderate hepatic impairment, the total dose is reduced to 250 mg, administered into one buttock, on days 1, 15, 29 and once monthly thereafter. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals General Medicine chemo drug e-o (4); inject cd list (8)
Chronic Dialysis Clinics Obstetrics Pharmacy Rehabilitation Clinics inject cd list (8)
27. Dosage Update for Hylan G-F 20
Effective retroactively for dates of service on or after January 1, 2010, providers may administer more than 48 units of Hylan G-F 20 (Synvisc-One, HCPCS code J7325) per day if bilateral knee injections are needed on the same day. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Chronic Dialysis Clinics
inject drug a-l (35)
28. Modification to Echography and Radiological Ultrasounds Frequency Restrictions
Effective for dates of service on or after February 1, 2011, reimbursement for split-billable echography and radiology services CPT-4 codes 76705, 76770, 76775, 76885, 76886, 93308, 93320 and 93321 will be limited to either:
One professional component (modifier 26) plus one technical component (modifier TC) for the same date of service, any provider; or
One complete component (modifier ZS) for the same date of service, same provider. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
General Medicine cardio (4); radi (9); radi dia ult (1)
radi (9); radi dia ult (1)
29. Age Range Expanded for Tdap Vaccine
Effective for dates of service on or after February 1, 2011, the Vaccines For Children (VFC) program will expand the age range for CPT-4 code 90715 (tetanus, diphtheria toxoids and acellular pertussis vaccine [Tdap] for individuals 7 years or older for intramuscular use) from 10 through 18 years of age to 7 through 18 years of age. The current VFC resolution can be viewed on the Advisory Committee on Immunization Practices page of the Centers for Disease Control website. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated General Medicine
Obstetrics Clinics and Hospitals
immun (11); vaccine (10)
30. Radiology Rate Reduction
Senate Bill 853 (Chapter 717, Statutes of 2010) created Welfare & Institutions Code (W&I Code), Section 14105.08, which specifies that Medi-Cal reimbursement rates for radiology services may not exceed 80 percent of the corresponding Medicare rate. Effective retroactively to dates of service on or after October 1, 2010, rates that exceed 80 percent of the 2010 Medicare rate will be reduced to that amount and the professional component percentage for these codes revised to match the Medicare amount. In addition, the rates for some codes that currently have no established price will be updated to 80 percent of the current Medicare rate to ensure that payments for these services comply with the new statute. Providers need take no action. An Erroneous Payment Correction (EPC) will be created to reprocess claims that were paid based on the prior reimbursement rates, and recoup payments as appropriate. This information is reflected in the following provider manual(s): Provider Manual(s) Page(s) Updated Clinics and Hospitals
radi (5); rates max (4, 8)
31. HIPAA-Compliant Transaction Standards to Change Effective January 1, 2012
The Department of Health Care Services (DHCS) and its new Fiscal Intermediary (FI), Affiliated Computer Services (ACS), have initiated a project to modify CA-MMIS to accept and process the newly mandated Health Insurance Portability and Accountability Act (HIPAA) electronic transaction versions.
Effective January 1, 2012, the X12 versions currently in use will be updated from X12 4010A1 to version 5010, and the National Council for Prescription Drug Programs (NCPDP) 5.1 and 1.1 to versions D.0 and 1.2, respectively. This is required for all providers who submit administrative electronic transactions, such as checking a recipient’s eligibility, filing claims, or receiving Remittance Advice Details (RADs) either directly or through a clearinghouse. Information on transactions not currently in use in CA-MMIS, such as the 999 and its impact on the 997, which is currently in use, will be addressed in future articles. The following transactions, currently in use, will be updated to adopt the new standards: Transaction Type Title Current Version New Version 270/271 Eligibility Benefit Inquiry/Response X12N 4010 X092 A1 X12N 5010 X279 E1, A1 * 276/277 Claim Status Request/Response X12N 4010 X093 A1 X12N 5010 X212 E1, E2 835 Payment/Advice X12N 4010 X091 A1 X12N 5010 X221 E1, A1 * 837 I Claims: Institutional X12N 4010 X096 A1 X12N 5010 X223 A1, E1, A2 * 837 P Claims: Professional X12N 4010 X098 A1 X12N 5010 X222 E1, A1 * NCPDP D.0 Retail Pharmacy: Interactive
NCPDP 5.1 NCPDP D.0, republished August 2010 * NCPDP 1.2 Retail Pharmacy: Batch NCPDP 1.1 NCPDP 1.2 * X12 errata published July 30, 2010; X12 errata and NCPDP corrections mandated October 13, 2010 via notice in the federal register. The new X12 version updates also impact the following transactions; however, CA-MMIS does not process these transaction types at this time: 278 – Referral requests and responses 837 D – Claims (dental); (these are processed at CD-MMIS) CA-MMIS is a pass-through for the following transactions to the Managed Care Plans, so modifications will be made at DHCS for these: 820 – Premium payments 834 – Enrollment and disenrollment in a health plan Version 5010 is the abbreviated way to refer to Version 005010 of the Accredited Standards Committee (ASC) X12 Technical Reports Type 3 (TR3s). The TR3s are the implementation guidelines for the ASC X12, some of which are named in HIPAA, and are required when conducting transactions electronically. The NCPDP creates and promotes data interchange standards for the pharmacy services sector of the healthcare industry. Those standards are available on the NCPDP website (www.NCPDP.org). NCPDP is accredited by the American National Standards Institute (ANSI), a private non-profit organization that oversees the development of standards for products and services, including the HIPAA electronic transaction standards. Implementation Timeline
On January 16, 2009, the federal Department of Health and Human Services (DHHS) announced that updated HIPAA-compliant versions of the electronic transactions will be required for use by all health plans, providers and clearinghouses that conduct business electronically. The following are key dates for the implementation of X12 5010, NCPDP D.0 and 1.2 in CA-MMIS: Companion Guides
Compliance Deadline for HIPAA 5010, NCPDP D.0 and 1.2
To be determined: dates will be communicated
to providers in the second quarter of 2011 To be determined: dates will be communicated
to providers in the
second quarter of 2011 December 2011 January 1, 2012 Additional information regarding the new HIPAA 5010 and NCPDP standards will be announced in future Medi-Cal Updates and website articles, including recommendations, checklists and other guidance to inform providers what they must do to be compliant by the January 1, 2012 deadline. HIPAA 5010/NCPDP D.0 and 1.2 – Frequently Asked Questions (FAQs)
Q: What is Version 5010 of the HIPAA X12 transaction mandate? A: HIPAA X12 version 5010, commonly referred to as HIPAA 5010, is a new set of standards that regulates the electronic transmission of specific health care transactions, including the following transactions:
Covered entities, such as health plans, health care clearinghouses and health care providers are required to comply with HIPAA standards. The current transaction standard is the X12 version 4010A1. Use of the new version 5010 of the X12 standards on or after the compliance date is required by federal law. The compliance date for use of the updated standards is January 1, 2012. Version 5010 accommodates ICD-10-CM values, whereas version 4010A1 does not. The 5010 implementation guides or Technical Report – Type 3 (TR3) documents specify how the transactions should be formatted, the data content that is required and allowable, and the structure of the transaction. Version 5010 includes the following types of changes: Consistency across transactions Accommodation of ICD-10-CM values New-use cases introduced by the health care industry Clarification of usage to eliminate ambiguity Removal of data content that is no longer used Q: What are NCPDP D.0 and 1.2 batch versions? A: HIPAA Version D.0 is the new National Council for Prescription Drug Programs (NCPDP) standard for Interactive Pharmacy Claims, eligibility inquiries and prior authorization. Version 1.2 is the new NCPDP standard for Batch Pharmacy Claims. Version D.0 will replace 5.1, and 1.2 will replace 1.1.
Q: Who will need to upgrade to the HIPAA 5010 and NCPDP D.0 and 1.2 standards? A: The following covered entities that conduct any of the affected electronic transactions are required to comply with HIPAA 5010 and the NCPDP D.0 and 1.2 standards, and may use a clearinghouse to assist with compliance: Healthcare Providers including:
Physicians Hospitals Ancillary and behavioral health care providers, including nurse practitioners and nurse practitioner primary care providers Pharmacies Dentists Payers/health plans Health care clearinghouses Note: Although software vendors are not included in the list of covered entities above, they will need to upgrade their products to support the new transaction versions.
Q: What transactions are specified in the HIPAA mandate? A: The following provider-related transactions processed in CA-MMIS are specified in the standards: Transaction Type Title Current Version New Version 270/271 Eligibility Benefit Inquiry/Response X12N 4010 X092 A1 X12N 5010 X279 E1, A1 * 276/277 Claim Status Request/Response X12N 4010 X093 A1 X12N 5010 X212 E1, E2 835 Payment/Advice X12N 4010 X091 A1 X12N 5010 X221 E1, A1 *
837 I Claims: Institutional X12N 4010 X096 A1 X12N 5010 X223 A1, E1, A2 * 837 P Claims: Professional X12N 4010 X098 A1 X12N 5010 X222 E1, A1 * NCPDP D.0 Retail Pharmacy: Interactive NCPDP 5.1 NCPDP D.0, republished August 2010 * NCPDP 1.2 Retail Pharmacy: Batch NCPDP 1.1 NCPDP 1.2 * X12 errata published July 30, 2010; X12 errata and NCPDP corrections mandated
October 13, 2010 via notice in the federal register. The new X12 version updates also impact the following transactions; however, CA-MMIS does not process these transaction types at this time: 278 – Referral requests and responses 837 D – Claims (dental); (these are processed at CD-MMIS) CA-MMIS is a pass-through for the following transactions to the Managed Care Plans, so modifications will be made at DHCS for these: 820 – Premium payments 834 – Enrollment and disenrollment in a health plan Note: Information on transactions not currently in use in CA-MMIS such as the 999 and its impact on the 997, which is currently in use, will be addressed in future articles. Q: Why is it necessary to upgrade to the new HIPAA transaction versions? A: The upgrade to versions 5010, NCPDP D.0 and 1.2 is important because it is mandated by the federal government. The new versions will contain improvements and will also be able to accommodate the forthcoming and mandatory ICD-10-CM and ICD-10-PCS code sets, which are scheduled to be implemented for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013. Q: How can providers and other covered entities prepare for the transition? A: Providers and organizations can prepare by reviewing the Technical Reports – Type 3 (TR3s) and NCPDP standards with their business partners, such as clearinghouses and software vendors. The TR3 documents are available for purchase from the Washington Publishing Company website (www.wpc-edi.com). The NCPDP standards can be purchased at www.NCPDP.org.
Q: When will the companion guides be available? A: Specific dates for revised companion guides and NCPDP Technical Specifications will be communicated to providers in the second quarter of 2011. Q: I bill using paper claims, does this affect me? A: At this time there is no anticipated HIPAA 5010-related impact to providers who bill on paper. However, further review of the impact of HIPAA 5010 on CA-MMIS may result in paper claims being affected. Those providers who bill using paper claims will be impacted once ICD-10-CM and ICD-10-PCS codes are mandated, effective for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013. Q: What if I’m not ready by the compliance deadline? A: According to the Centers for Medicare & Medicaid Services (CMS) guidelines, any 4010/4010A1, NCPDP 5.1 or 1.1 batch transaction submitted on or after January 1, 2012 will be rejected due to HIPAA non-compliance and will not be processed. This will ultimately result in non-payment of claims. If CMS revises its compliance policy, notifications will be announced to providers. Q: What is the scheduled implementation date for ICD-10-CM? A: According to CMS compliance dates, implementation for ICD-10-CM and ICD-10-PCS is scheduled for outpatient claims with dates of service, and inpatient claims with dates of discharge, on or after October 1, 2013. The Department of Health Care Services (DHCS) has already been undertaking transition activities, but project planning by DHCS and its new Fiscal Intermediary (FI), Affiliated Computer Services (ACS), will commence on January 1, 2011. Q: When will CA-MMIS accept HIPAA 5010 and NCPDP D.0 and 1.2? A: Providers may submit the new transactions for processing to CA-MMIS beginning on December 1, 2011. Print Article | Return to Top
2toccah (iv)
inject cd list (19)
inject drug m-z (34)
subacut lev (1,3)