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Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC

Medi-Cal 2013 Reimbursements. Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2013. 1. 1. Paper Claim Submission. Clear and Scannable Send Only Necessary Documentation Do Not Use Highlight Markers Do Not Use Pencils

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Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC

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  1. Medi-Cal 2013 Reimbursements Bernie Betlach CLS, MT(ASCP) Laboratory Consultant / Medi-Cal Xerox State Healthcare, LLC November 2013 1 1

  2. Paper Claim Submission Clear and Scannable Send Only Necessary Documentation Do Not Use Highlight Markers Do Not Use Pencils Do Not Submit Handwritten Forms 2 2

  3. Multiple Procedure Billing Use a Single Claim Line to bill the same Lab Procedure, more than once, on the same day Indicate Quantity in the Units Column Exceptions are Surgical Pathology CPT-4 codes 88300 through 88309 when billed for separate sites must be billed on separate claim lines with a maximum of one unit for each line. See: path bil cms 2, path surg 2 3 3

  4. Claim Form Units Field • On Appeals submit the original claim with the total number of units • Corrected if necessary • Medi-Cal will only pay what is billed See: appeal form 1 4

  5. Laboratory Services Reservation System (LSRS) • Allows Laboratories to Reserve or Determine if a Procedure is Within the Medi-Cal Frequency Limits for that Month • Monthly Frequency Limits for all Lab Services are: ▪ Per Recipient ▪ Per Service

  6. LSRS (cont’d) • Web Based, on the Internet • Calling the Help Desk • Allowing the System to Make a Reservation if a Available by Submitting a Claim 3 Ways to Make a Reservation:

  7. LSRS (cont’d) • Common Mistake When Making a Web Based Reservation: • Use only the Patient’s 9 character Identification Number: • Use this: 87709090D • Do Not Use: 87709090D71249 • Exception: The Longer Identification Numbers as with Presumptive Eligibility

  8. Quantitative Drug Tests Requiring Justification • Documentation must be Submitted with a Claim Justifying the use of a Quantitative Determination of Drug level rather than Qualitative Determination (screening). • CPT-4 code Description • 82101 Alkaloids, urine, quantitative • 82145 Amphetamine or methamphetamine • 82205 Barbiturates, not elsewhere specified • 82649 Dihydromorphinone • 83840 Methadone • 83925 Opiate(s), drug and metabolites, each procedure • 83992 Phencyclidine (PCP) • See: path drug 1,2

  9. Maximum Reimbursement • Laboratory Services are paid based on the least amount of the following: • The amount billed • The charge to the general public • Medicare’s maximum allowance • Medi-Cal’s maximum allowance See: Oct. 2008, Bulletin 412 Cal.Code Regs., tit. 22, § 51529, subd.(a)(2)(B)

  10. Rate Update for Laboratory Services • Effective on or after July 22, 2013: • Reimbursement rates for certain laboratory services that were higher than 80 percent of the 2011 and/or 2012 Medicare rate will change. • Any claims processed on or after July 22, 2013, with a date of service in 2011, 2012 or 2013, will be subject to the updated rates. • See: California Code of Regulations (CCR), Title 22, Section 51137.2

  11. Presumptive Eligibility Program New Benefit for Pregnant Women • Effective for dates of service on or after November 1, 2012: • CPT-4 code 87147 (culture typing; other than immunofluorescence [e.g., agglutination grouping], per antiserum) • See: presum 20

  12. Cervical Cancer Screening Age Eligibility Update • Effective for dates of service on or after January 1, 2013: • Women Must be 21 Years of Age or Older to be Eligible for Cervical Cancer Screening Consisting of a Pap test, a Pelvic Examination to Perform a Pap Test and the Necessary Follow-Up Cervical Diagnostic Services. • See: ev woman 8

  13. Age Eligibility Update for Cervical Screening (cont’d) • Effective for dates of service on or after May 1, 2013: • Cervical screening codes are restricted to women ages 21 through 65 regardless of sexual history • Exceptions: • Received a diagnosis of a high-grade precancerous cervical lesion within the past 20 years. • In utero exposure to diethylstilbestrol (DES). • Immunocompromised status.

  14. Age Eligibility Update for Cervical Screening (cont’d) • Exceptions (cont’d): • Prior atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion (LSIL), or CIN 1 test result. • Over the age of 65 who did not have adequate negative prior screening. • See: Path Cyto 2

  15. Hepatitis C Screening Codes Policy Update • Effective for dates of service on or after December 1, 2012: • CPT-4 codes: • 86803 (hepatitis C antibody) • 86804 (hepatitis C antibody; confirmatory test) • May be Reimbursed with non-specific ICD-9-CM diagnosis codes: • V70.0 • V70.5 • V70.9 • See: path bil 1

  16. Hepatitis C Antibody Added to CLIA Tests Waive List • Effective for dates of service on or after February 1, 2013: • CPT-4 code 86803 (Hepatitis C antibody) may be billed with modifier QW • See: path bil 8

  17. BRCA Test for Uncommon Variants CPT-4 Code 81213 is now a Medi-Cal Benefit • Effective for dates of service on or after January 1, 2013: • Once-in-a-lifetime procedure • Requires a Treatment Authorization Request (TAR) documenting the following: • A negative result in the full sequence analysis and common duplication/deletion variants in BRCA (CPT-4 code 81211), • One or more criteria listed under CPT-4 code 81211 • See: path molec 5

  18. Updated Policy for Allergen Specific IgE Testing • Effective for dates of services on or after May 1, 2013: • 86003 (allergen specific IgE) will be Reimbursed for Asthma Patients. • Requiring Treatment at Step 2 or higher according to NAEPP 2007). • The test is needed to determine the potential sensitivity to perennial indoor inhalant allergens to which the patient is exposed. • Additionally, an Explanation as to why other allergy tests were not satisfactory must be provided to justify medical necessity. • See: allergy 1,2

  19. HIPAA Code Conversion for Local Modifier ZS • DHCS will discontinue use of local modifier ZS. • Scenario 1: The facility and physician each bill for their respective component of the service with modifiers 26 or TC. • Scenario 2: Full Fee Billing – The physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component, according to their mutual agreements. • Scenario 3: Standard Billing – The facility bills for both the technical and professional components and reimburses the physician for the professional component, according to their mutual agreements.

  20. HIPAA Code Conversion for Local Modifier ZS (cond’t) • Public comment period ended October 31, 2013

  21. Molecular Pathology and Diagnostics • Only the Procedures listed in the Provider Manual are • Medi-Cal Covered Services. Reimbursement Requirements for Each Procedure include some or all of the following: • Treatment Authorization Request (TAR) and claim documentation requirements. • Allowable diagnosis (ICD-9-CM) codes. • Once-in-a-lifetime and other frequency limitations for reimbursement. • See: path molec

  22. Molecular Pathology and Diagnostics(cont’d) • Billing: • Dates of Service Prior to Sept. 1, 2013: • Some Procedures are Priced. • Crosswalk to Stacked Codes based on MML Matters 7654. Example:        Procedure Code Billed : 81295        Stacked code set : 83891(one time) 83898(seven        times)+83909(nine times) + 83912(one time). • A list of the Crosswalk Must be Included with the Claim

  23. Molecular Pathology and Diagnostics(cont’d) • Billing (cont’d): • Dates of Service on or after Sept. 1, 2013: • Rate set by Medi-Cal • Based on a Medicare rate(80%) • Crosswalk to stacked codes

  24. Cystic Fibrosis Reimbursement • Issues with Underpayment and Overpayment Problems are Being Corrected. • 2 Step Process: • Claims being held, have been released. • A follow up Erroneous Payment Correction (EPC) will be forthcoming to make necessary take backs or payments. • In addition, any payments made with the 8A modifier after date of Service October 1, 2012 will be recouped.

  25. Family PACT Update on Urine Cultures • Effective for dates of service on or after November 1, 2013: • CPT 87086 (Urine Culture, Quantitative Colony Count) is • No Longer a benefit of the Family PACT Program. • The following Reflex Susceptibility Tests will also not be Reimbursed: • 87818 • 87184 • 87186 • See: FPACT ben sec 13, ben grid 9, lab 11-13

  26. Family PACT and Medi-Cal Family Planning Code Conversions • Effective for dates of service on or after December 30, 2013 • DHCS will discontinue use of the most current Family PACT Program and Medi-Cal Family Planning HCPCS local codes (the S-Codes). • The local codes will be replaced with HCPCS national HIPAA compliant codes. • Ref: 1996 Public Law 104-191, 45 CFR 162.1000

  27. ICD-10 • Primary baseline crosswalk is CMS General Equivalency Maps (GEMS) • Medi-Cal providers are encouraged to take the ICD-10 Provider Readiness Survey. • https://www.surveymonkey.com/s/icd-10survey • Mandatory implementation date October 1, 2014

  28. Bernie Betlach CLS, MT(ASCP) Medical Lab Consultant Xerox State Healthcare, LLC 820 Stillwater Road West Sacramento, CA 95605 bernard.betlach@xerox.com 28 28

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