Medi-Cal Update

Long Term Care | April 2013 | Bulletin 434

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1. Extension of End Date for ASC X12N 4010A1 and NCPDP 5.1/1.1 Transactions

An article announcing a March 31, 2013, end date for acceptance of claims in the ASC X12N 4010A1 and NCPDP 5.1/1.1 transactions was published in the NewsFlash area and in the March 2013 Medi-Cal Update. The Department of Health Care Services (DHCS) has decided to extend the end date as follows.

After April 30, 2013, DHCS will no longer accept claims in the ASC X12N 4010A1 and NCPDP 5.1/1.1 formats.

Due to HIPAA non-compliance, any 4010/4010A1 or NCPDP 5.1/1.1 batch transactions submitted after this date will be rejected and result in non-payment of claims.

All ASC X12N 837 v.4010A1 transactions submitted on or after May 1, 2013, will be deleted with CMC error codes 58: Media type/claim type not valid for this submitter and 55: Submitter/claim type not approved for included attachment.

Submitters who have not certified or converted to ASC X12N 5010 and NCPDP D.0/1.2 formats can contact the Computer Media Claims (CMC) Help Desk by calling the Telephone Service Center (TSC) at 1-800-541-5555, option 4 then option 2, to schedule testing.

Additional information can be located on the HIPAA/5010/4010/NCPDP page located under the References tab of the Medi-Cal website.

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2. Skilled Nursing Facilities: Quality Assurance Fee for Rate Year 2012 – 2013 Update

The March 2013 Medi-Cal Update bulletin included the article “Skilled Nursing Facilities: Quality Assurance Fee for Rate Year 2012 – 2013,” which inadvertently reversed the listed Quality Assurance Fees (QAF) for all non-exempt Freestanding Skilled Nursing Facilities Level B (FS/NF-B), Freestanding Adult Subacute Nursing Facilities Level B (FSSA/NF-B) and Freestanding Pediatric Subacute Facilities Level B (PSA/NF-B).

The corrected QAFs are as follows:

Providers may access information about the QAF program on the Quality Assurance Fee page of the DHCS website.

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3. Subacute Care Billing Code Conversions

Effective for dates of service on or after October 1, 2012, the Department of Health Care Services (DHCS) 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 were discontinued. These interim codes were 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 table below details the new codes in parallel to the interim codes they replaced.

Providers are reminded that they should not use Place of Service codes “99” (Other Place of Service) or “27” (Unassigned) in conjunction with modifier HA (pediatric) or modifier HB (adult) to identify subacute services. Modifier U2 will serve this purpose. However, along with modifier U2, providers must specify the appropriate Place of Service.

Interim Code Interim Code Description Interim Code Rate Proposed National Code/Modifier National Code Rate Billing Instructions
X9922 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
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$34.30
Procedure Type P:
$34.30
  • Use modifier U2 to identify subacute level of care.
X9924 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 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
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$73.20
Procedure Type P:
$73.20
  • 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 moderate 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:
  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of moderate complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$80.10
Procedure Type P:
$80.10
  • 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:
  • A problem focused interval history;
  • A problem focused examination;
  • Medical decision making that is straightforward or of low complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$27.50
Procedure Type P:
$27.50
  • 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;
  • An expanded problem focused examination; and
  • Medical decision making of moderate complexity
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:
  • An expanded problem focused interval history;
  • An expanded problem focused examination; and
  • Medical decision making of moderate complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$37.80
Procedure Type P:
$37.80
  • 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
U2 – Medicaid Level of Care 2, as defined by each state
$45.80
  • 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
U2 – Medicaid Level of Care 2, as defined by each state
$37.60

$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 history;
  • A problem focused examination; and
  • Straightforward medical decision making
Procedure Type N:
$30.60 Procedure Type P:
$30.60
99241 – Office consultation, for a new or established patient, which requires these three key components:
  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making
and
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 Office consultation, for a new or established patient, which requires these three key components:
  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
Procedure Type N: $30.60
Procedure Type P:
$30.60
99242 – Office consultation, for a new or established patient, which requires these three key components:
  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
and
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
and
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
$71.40 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
and
U2 – Medicaid Level of Care 2, as defined by each state
$81.40
  • Use modifier U2 to identify subacute level of care.
X9944 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 high complexity
$71.40 99245 – 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 high complexity
and
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:
  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making
Procedure Type N:
$30.60
Procedure Type P:
$30.60
99251 – Inpatient consultation for a new or established patient, which requires these three key components:
  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making
and
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;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
Procedure Type N:
$30.60
Procedure Type P:
$30.60
99252 – Inpatient consultation for a new or established patient, which requires these three key components:
  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$32.46
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
Procedure Type N:
$51.00
Procedure Type P:
$51.00
99253 – Inpatient 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
and
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 Initial subacute care consultation, for a new or established patient, that requires these three key components:
  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of moderate complexity
$71.40 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
and
U2 – Medicaid Level of Care 2, as defined by each state
$65.01
  • Use modifier U2 to identify subacute level of care.
X9954 Initial subacute care consultation, for a new or established patient, that requires these three key components:
  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of high complexity
$71.40 99255 – 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 high complexity
and U2 – Medicaid Level of Care 2, as defined by each State
$86.25
  • 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:
  • A problem focused interval history;
  • A problem focused examination; and
  • Medical decision making that is straightforward or of low complexity
$12.20 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 interval history;
  • A problem focused examination; and
  • Medical decision making that is straightforward or of low complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$27.50
Procedure Type P:
$27.50
  • Use modifier U2 to identify subacute level of care.
X9958 Follow-up subacute care consultation, for an established patient, that requires at least two of these three key components:
  • An expanded problem focused interval history;
  • An expanded problem focused examination; and
  • Medical decision making of moderate complexity
$19.40 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 interval history;
  • An expanded problem focused examination; and
  • Medical decision making of moderate complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$37.80
Procedure Type P:
$37.80
  • 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
$30.60 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
and
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:
  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making
$30.60 99251 – Inpatient consultation for a new or established patient, which requires these three key components:
  • A problem focused history;
  • A problem focused examination; and
  • Straightforward medical decision making
and
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.
X9964 Confirmatory subacute care consultation, for a new or established patient, that requires these three key components:
  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
$30.60 99252 – Inpatient consultation for a new or established patient, which requires these three key components:
  • An expanded problem focused history;
  • An expanded problem focused examination; and
  • Straightforward medical decision making
and
U2 – Medicaid Level of Care 2, as defined by each state
Procedure Type N:
$32.46
Procedure Type P:
$32.46
  • Use modifier U2 to identify subacute level of care.
X9966 Confirmatory 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
$51.00 99253 – Inpatient 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
and
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 Confirmatory subacute care consultation, for a new or established patient, that requires these three key components:
  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of moderate complexity
$71.40 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
and
U2 – Medicaid Level of Care 2, as defined by each state
$65.01
  • Use modifier U2 to identify subacute level of care.
X9970 Confirmatory subacute care consultation, for a new or established patient, that requires these three key components:
  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of high complexity
$71.40 99255 – 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 high complexity
and
U2 – Medicaid Level of Care 2, as defined by each state
$86.25
  • Use modifier U2 to identify subacute level of care.
Note:

Procedure Type “N” is for Medicine type codes; Procedure Type “P” is for Podiatry type codes. If the National Code rate differs from the Interim Code rate, the National Code rate will be applied.

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

Provider Manual(s) Page(s) Updated
General Medicine subacut code (1–4); subacut lev (4); non ph (10); rates max (5); eval (3, 7)
Long Term Care subacut code (1–4); subacut lev (4)
Obstetrics rates max (5); non ph (10); eval (3, 7)
Outpatient Clinics and Hospitals non ph (10); subacut code (1–4); subacut lev (4); rates max (5)
Pharmacy subacut lev (4)
Rehabilitation Clinics non ph (10); eval (3, 7)
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4. New CLLS Rate Methodology Posted and Data Submission Deadline Extended

Assembly Bill 1494 (Chapter 28, Statutes of 2012) authorizes the Department of Health Care Services (DHCS) to develop a new rate methodology for clinical laboratory and laboratory services (CLLS). The new rate methodology determines rates that are comparable to payment amounts received by other payers. To establish this methodology, AB 1494 directs CLLS providers that billed Medi-Cal in 2011 to submit data reports based on the 2011 calendar year.

DHCS must determine the average lowest price providers receive from third-party payers other than Medi-Cal and develop rates for these services at either the lowest rate other payers are paying or at 80 percent of the Medicare rate, whichever is lower. DHCS held several stakeholder meetings between August 2012 and March 2013 to finalize the data elements to be collected and the format to be used for data submission.

DHCS has posted the final rate methodology proposal and electronic spreadsheet that providers must use to electronically submit fee schedules to DHCS on the Clinical Laboratory and Laboratory Services Rate Methodology Change page of the DHCS website. Providers must email their completed fee schedules spreadsheet to labcomments@dhcs.ca.gov. All data submissions must be submitted to DHCS electronically.

To ensure providers have adequate time to prepare and submit the data, the deadline for the submission has been extended to May 31, 2013. The data reports submitted to DHCS must be certified by the provider's certified financial officer or an authorized individual. Providers' data submissions are confidential.

For more information, providers may email DHCS at labcomments@dhcs.ca.gov or visit the Clinical Laboratory and Laboratory Services Rate Methodology Change page of the DHCS website.

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5. Change of Contact Information: Systems of Care Division, Los Angeles Office

Effective immediately, contact information for the Systems of Care Division, Los Angeles Office, is updated as follows:

Department of Health Care Services
Systems of Care Division
Los Angeles Office - EPSDT Unit
311 South Spring Street, Suite 701
Los Angeles, CA 90013-1211
P.O. Box 60172, MS 4513
Los Angeles, CA 90060-0172
(855) 347-9227
Fax (916) 440-5758

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

Provider Manual(s) Page(s) Updated
Home Health Agencies/Home and Community-Based Services ped (3); tar field (2)
Adult Day Healthcare Centers
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Heroin Detoxification
Hospice Care Program
Inpatient Services
Long Term Care
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
tar field (2)
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6. Subscribe Today to Receive Medi-Cal Notifications via Email

Providers are invited and encouraged to subscribe to the Medi-Cal Subscription Service (MCSS), where subscribers receive email notification of urgent, high-impact announcements and/or monthly Medi-Cal Update bulletins when posted on the Medi-Cal website. Subscribers can choose specific provider communities or subject matters, making it easier to stay up-to-date on the latest Medi-Cal news.

Subscribing to MCSS is easy; go to the MCSS Subscriber Form on the Medi-Cal website and complete the following steps:

  1. Enter an email address and a ZIP code
  2. Select the specific subject matter areas of interest for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts
  3. A confirmation email will be sent to the registered email; click the subscription confirmation link and the registration process is complete

    Note:

    If subscribers are unable to find the subscription confirmation email in their inbox, they should check their junk email folder.

For more information about MCSS, please visit the MCSS Help page.

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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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