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Important Updates to Claims

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Physician Administered Drugs (PAD)

As a follow up to the January 22, 2020 memo and in order to comply with DHCS requirements, this is a reminder that all primary and secondary claims for Physician Administered Drugs (PAD) must be billed with the following information:

  • A qualifier
  • National Drug Code (NDC)
  • Unit of measure and quantity – units of measure include qualifier F2 (International Unit), GR (Gram), ML (Milliliter) and UN (Unit)

Claims with incomplete or missing information will be denied with explain reason code 522- Physician Administered Drug Information Missing or Invalid.

DME Rates Adjustment

Through an internal audit process the Alliance has identified discrepancies between the Medi-Cal Manual and the Medi-Cal Fee Schedule. Effective 9/1/2020, the Alliance will adjust all pricing to reflect rates from the Medi-Cal fee schedule.

The Medi-Cal Fee Schedule can be found at the following link:

https://files.medi-cal.ca.gov/Rates/RatesHome.aspx

Billing Instructions for Telehealth Place of Service and Modifier Requirements

Based on a recent analysis of Telehealth claims the Alliance would like to remind providers about properly coding for these services. Both a modifier and a place of service code are required data elements for claims submitted on a CMS 1500 claim form. Use of incorrect place of service codes and missing or incorrect modifiers will result in the claim being denied.

The following code combinations are required for all telehealth claims: CMS 1500 claim form requirements:

  1. Place of Service (box 24)
  • Use code 02
  1. Modifier (box 24D)
    • Use modifier 95 for Synchronous Telemedicine or use modifier GQ for Asynchronous Telemedicine

UB-04 claim from requirements:

  1. Modifier (box 44)
    • Use modifier 95 for Synchronous Telemedicine or use modifier GQ for Asynchronous Telemedicine

Billing Guidelines for COVID-19 Testing

Providers who encounter patients for the sole purpose of providing a COVID 19 swab test should bill with the following code combinations:

  • 99211: OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES.

In combination with:

  • 99000: HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE OFFICE TO A LABORATORY

And one of the following diagnosis codes that best captures the circumstances of the patient’s health:

  • 59: ENCOUNTER FOR SCREENING FOR OTHER VIRAL DISEASES
  • 818: ENCOUNTER FOR OBSERVATION FOR SUSPECTED EXPOSURE TO OTHER BIOLOGICAL AGENTS RULED OUT
  • 828: CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER VIRAL COMMUNICABLE DISEASES
  • 1: COVID 19

Providers who are administering the COVID 19 test in tandem with an E&M office visit regardless of the level code will not separately be reimbursed for the handling and/or conveyance of specimens as it is considered included in the reimbursement of the E&M code.

A referral is not required for linked members, providers seeing non-linked members should use the EMG field or condition code 81 as specified in previous billing guidelines and communications.

Providers seeing patients for all other conditions and in the course of that treatment elect to administer the COVID 19 testing should bill according the appropriate level of service, code diagnosis for the condition the patient is being seen for as well as the appropriate COVID 19 testing diagnosis code.

For claims questions, please call a Claims Customer Service Representative at (831) 430-5503 or (800) 700-3874 ext. 5503.