Local Educational Agency (LEA) Medi-Cal Billing Option...

Local Educational Agency (LEA) Medi-Cal Billing Option Contents PART 2 – MEDI-CAL BILLING AND POLICY FOR OUTPATIENT SERVICES

2 – Contents for LEA Billing and Policy i Outpatient Services – LEA 391 May 2007

The Contents is a list of manual sections contained in the Part 2 manual, Outpatient Services for Local Educational Agency (LEA). Section titles appear in alphabetical order. The “locator key” is an abbreviated form of the section title at the top of each page for skimming and identifying sections. For detailed topic entries within Part 1 and Part 2, refer to the Manual Index in the Indexes and Glossary manual. Section Title Locator Key A Appeal Form Completion ................................................................................... appeal form C California Children’s Services (CCS) Program ....................................................... cal child California Children’s Services (CCS) Program Approved Hospitals ................ cal child appr California Children’s Services (CCS) Program Billing ......................................... cal child bil CCS Program Billing Guidelines California Children’s Services (CCS) Program Billing Example: UB-04 Claim Form....................................................................................... cal child bil ub California Children’s Services (CCS) Program County Office Directory........ cal child county California Children’s Services (CCS) Program Eligibility ................................... cal child elig California Children’s Services (CCS) Program Medical Therapy Program ...... cal child med California Children’s Services (CCS) Program Provider Paneling .................. cal child panel Individual Provider Paneling Application for Physicians and Podiatrists Individual Provider Paneling Application for Allied Health Care Professionals

(continued)

2 – Contents for LEA Billing and Policy ii Outpatient Services – LEA 379 May 2006

Section Title Locator Key

C California Children’s Services (CCS) Program Referrals .................................... cal child ref California Children’s Services (CCS) Program Service Authorization Request (SAR) ............................................................................................... cal child sar New Referral CCS/GHPP Client Service Authorization Request (SAR) Established CCS/GHPP Client Service Authorization Request (SAR) CCS/GHPP Discharge Planning Service Authorization Request (SAR) California Children’s Services (CCS) Program Service Code Groupings ........... cal child ser California Children’s Services (CCS) Program Special Care Centers ............. cal child spec CIF Completion .......................................................................................................... cif co CIF Special Billing Instructions for Outpatient Services .......................................... cif sp op CIF Submission and Timeliness Instructions ............................................................ cif sub D Dental Benefits .......................................................................................................... dental F Forms: Legibility and Completion Standards ....................................................... forms leg Forms Reorder Request: Guidelines ................................................................... forms reo Forms Reorder Request: Inpatient and Outpatient Services ............................. forms reo io G Genetically Handicapped Persons Program (GHPP) ............................................... genetic H HCPCS Introduction................................................................................................... hcpcs HCPCS Level III Interim Code List: Reimbursable Medi-Cal-Only Codes ............. hcpcs iii

2 – Contents for LEA Billing and Policy iii Outpatient Services – LEA 379 May 2006


L Local Educational Agency (LEA) ............................................................................... loc ed Local Educational Agency (LEA): A Provider’s Guide ...................................... loc ed a prov Local Educational Agency (LEA) Billing and Reimbursement Overview................................................................. loc ed bil Local Educational Agency (LEA) Billing Codes and Reimbursement Rates ....................................................... loc ed bil cd Local Educational Agency (LEA) Billing Examples ............................................ loc ed bil ex Local Educational Agency (LEA) Eligible Students .............................................. loc ed elig Local Educational Agency (LEA): Individualized Plans......................................................................................... loc ed indiv Local Educational Agency (LEA) Rendering Practitioner Qualifications .............................................................. loc ed rend Local Educational Agency (LEA) Service: Hearing ..................................... loc ed serv hear Local Educational Agency (LEA) Service: Nursing ...................................... loc ed serv nurs Local Educational Agency (LEA) Service: Occupational Therapy .............................................................................. loc ed serv occu Local Educational Agency (LEA) Service: Physical Therapy ........................................................................................ loc ed serv phy Local Educational Agency (LEA) Service: Physician Billable Procedures ............................................................ loc ed serv physician Local Educational Agency (LEA) Service: Psychology/Counseling ........................................................................... loc ed serv psych Local Educational Agency (LEA) Service: Speech Therapy ......................................................................................... loc ed serv spe Local Educational Agency (LEA) Service: Targeted Case Management ..................................................................... loc ed serv targ Local Educational Agency (LEA) Service: Transportation (Medical) .......................................................................... loc ed serv trans Local Educational Agency (LEA) Service: Vision Assessments .................................................................................... loc ed serv vis

2 – Contents for LEA Billing and Policy iv Outpatient Services – LEA 427 April 2010


M Modifiers: Approved List ...................................................................................... modif app O Other Health Coverage (OHC) ................................................................................. oth hlth Other Health Coverage (OHC): CPT-4 and HCPCS Codes ............................... oth hlth cpt P Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) .................... prov bil R Remittance Advice Details (RAD) ......................................................................... remit adv Remittance Advice Details (RAD) Examples: Outpatient Services .................... remit ex op Remittance Advice Details (RAD): Payments and Claim Status .......................... remit pay Resubmission Turnaround Document (RTD) Completion .................................. resub comp S Share of Cost (SOC): UB-04 for Outpatient Services ........................................... share op Sign Language Interpretation ....................................................................................... sign U UB-04 Completion: Outpatient Services ........................................................... ub comp op UB-04 Special Billing Instructions for Outpatient Services .................................. ub spec op UB-04 Tips for Billing: Outpatient Services .......................................................... ub tips op

appeal form Appeal Form Completion 1

2 – Appeal Form Completion December 2009

This section describes the instructions for completing an Appeal Form (90-1). An appeal is the final step in the administrative process and a method for Medi-Cal providers with a dispute to resolve problems related to their claims. Appeal Form (90-1) An appeal may be submitted using the Appeal Form (90-1). A sample

completed Appeal Form (see Figure 1) and detailed instructions are on a following page.

Note: Do not submit an appeal if a claim is still in suspense. Supporting Documentation Necessary documentation, such as those listed below, should be for Appeals submitted with each appeal to help appeals examiners perform a

thorough review of the case. All supporting documentation must be legible. A copy of any of the following attachments is acceptable:

• Claim, corrected if necessary

• All Remittance Advice Details (RADs)

• Explanation of Medicare Benefits (EOMB) or Medicare Remittance Notice (MRN)

• Other Health Coverage (OHC) payments or denials

• All Claims Inquiry Forms (CIFs), Claims Inquiry Acknowledgments, CIF Response Letters, or other dated correspondence to and from the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) to document timely follow-up

• Treatment Authorization Request (TAR)

• Manufacturer’s invoice or catalog page

• Report for “By Report” procedures

• Completed sterilization Consent Form (Form PM 330)

Automated Remittance Data Services (ARDS) electronic transmissions are intended for the purpose of an automated reconciliation of computer media records and are not acceptable forms of documentation for timeliness in appeals. Although the transmissions are from the state, the methods of creating paper facsimiles vary according to provider software and are not standard.

appeal form 2

2 – Appeal Form Completion November 2010

Over-One-Year Appeals submitted for claims billing services rendered more than Dates of Service 13 months prior to the appeal date should include one of the following,

if available, to show proof of recipient eligibility:

• Copy of the Point of Service (POS) device printout, Internet eligibility response or state-approved vendor software screen print, with an Eligibility Verification Confirmation (EVC) number

• RAD showing payment for same recipient for the same month of service billed

• Copy of the original County Letter of Authorization (LOA) form (MC-180) signed by an official of the county

Requesting Claim When requesting a claim adjustment, submit a copy of the Adjustments Remittance Advice Details (RAD) on which the claim line was paid and all other pertinent attachments, including timeliness

documentation. Timeliness: Providers must submit an appeal in writing within 90 days of the 90-Day Deadline action/inaction precipitating the complaint. Failure to submit an appeal

within this 90-day time period will result in the appeal being denied. (See California Code of Regulations, Title 22, Section 51015.)

Timeliness The only acceptable documentation to verify timely submission Verification of a claim is a copy of a RAD, Resubmission Turnaround Document (RTD), Claims Inquiry Response Letter, Claims Inquiry Acknowledgment, or any dated correspondence from the DHCS FI containing a Claims Control Number (CCN) or Correspondence Reference Number (CRN) with a Julian date falling within the six-month billing limit for the claim submission. A copy of the CIF without its accompanying Claims Inquiry Acknowledgment does not prove timely follow-up and may cause an appeal to be denied.

appeal form 3


Where to Submit Appeals Providers should mail appeals to the FI at the following address:

Attn: Appeals Unit HP Enterprise Services P.O. Box 15300 Sacramento, CA 95851-1300

FI Acknowledgement The FI will acknowledge each appeal within 15 days of receipt and of Appeal make a decision within 45 days of receipt. If The FI is unable to make a decision within this time period, the appeal is referred to the professional review unit for an additional 30 days.

If the appealed claim is approved for reprocessing, it will appear on a future Remittance Advice Details (RAD). The reprocessed claim will continue to be subject to Medi-Cal policy and claims processing criteria and could be denied for a separate reason.

Appeal Response Letter The FI will send a letter of explanation in response to each appeal. Providers who are dissatisfied with the decision may submit subsequent appeals. In these cases, indicate the reason for appealing the decision in the Reason For Appeal field (Box 13) of the Appeal Form, and attach a copy of the claim and any supporting documentation (including timeliness documentation). Judicial Remedy: Providers who are not satisfied with the FI’s decision after completing One-Year Limit the appeal process may seek relief by judicial remedy not later than

one year after the appeal decision. Providers who elect to seek judicial relief may file a suit in a local court, naming the Department of

Health Care Services (DHCS) as the defendant. (See Welfare and Institutions Code, Section 14104.5.)

appeal form 4

2 – Appeal Form Completion January 2008

Figure 1. Sample Completed Appeal Form (90-1): Denial Resubmissions, Underpayment Reconsiderations and Overpayment Returns.

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Explanation of Form Items Each numbered item below refers to an area on the Appeal Form shown on a previous page. Item Description

1. Appeal Reference Number. For FI use only. 2. Document Number. The pre-imprinted number identifying

the Appeal Form. This number can be used when requesting information about the status of an appeal.

3. Provider Name/Address. Enter the following information:

Provider Name, Street Address, City, State, and ZIP code. 4. Provider Number (required field). Enter the provider

number. Without the correct provider number, appeal acknowledgement may be delayed.

5. Claim Type (required field). Enter an “X” in the box

indicating the claim type. Only one box may be checked. 6. Statement of Appeal. For information purposes only. 7. Patient’s Name or Medical Record Number. Enter up to the

first 10 letters of the patient’s last name or the first 10 characters of the patient’s medical record number.

8. Patient’s Medi-Cal ID Number/SSN (required field). Enter

the recipient ID number that appears on the plastic Benefits Identification Card (BIC) or paper Medi-Cal ID card.

9. Delete. If an error is made, enter an “X” in this box to delete

the corresponding line. When Box 9 is marked “X”, the information on the line will be “ignored” by the system and will not be processed as an appeal line. Enter the correct billing information on another line.

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Item Description

10. Claim Control Number (required field if appealing a previously adjudicated claim). Enter the 13-digit number assigned by the FI to the claim line in question. (This number is found on the Remittance Advice Details [RAD]). This field is not required when appealing a non-adjudicated claim (for example, a “traced” claim that could not be located). 11. Date of Service. In six-digit format (MMDDYY) enter the date

the service was rendered. For claims billed in a “from-through” format, you must enter the “from” date of service.

12. RAD Code or EOB/RA Code. When appealing an

adjudicated claim, enter the RAD message code for the claim line (for example, 010, 072, 401).

13. Reason for Appeal. Indicate the reason for filing an appeal.

Be as specific as possible. Include all supporting documentation to help examiners properly research the complaint.

14. Common Appeal Reason. Check one of these boxes if

applicable. Include a copy of the claim and supporting documentation (for example, TAR, EOMB). This box is for convenience only. Leave Box 13 blank if this box is used.

15. Signature. The provider or an authorized representative must

sign the Appeal Form.

appeal form 7

2 – Appeal Form Completion March 2011

Completion Complete the fields on the Appeal Form (90-1) according to the type of inquiry, as described in the following paragraphs. Resubmission, underpayment and overpayment requests for the same recipient may be combined on one form. However, each appeal should include only one recipient. Use the correct recipient Medi-Cal ID number on the appeal.

Required Fields Always complete Boxes 3, 4, 5, 7, 8, 10, 11 and 12 – these are

required fields for all inquiry types. Boxes 4, 5, 8 and 10 (Provider Number, Claim Type, Patient’s Medi-Cal I.D. Number/SSN and Claim Control Number) must be completed to process the appeal. If these fields are left blank, providers may receive an appeal rejection letter requesting resubmission of a corrected Appeal Form and all supporting documentation and proof of timely follow-up and submission.

Note: The correct recipient ID number must be entered in Box 8

(Patient’s Medi-Cal I.D. No./SSN) even if the RAD reflects an incorrect recipient ID number.

Appealing a Denial If appealing a denial, enter the denial code from the RAD in Box 12. Underpayment and If requesting reconsideration of an underpayment or overpayment, Overpayment enter the payment code from the RAD in Box 12. (See Figure 1 on a Adjustments previous page.) If requesting an adjustment, attach a legible copy of the original claim

form, corrected if necessary, and a copy of the corresponding paid RAD. If requesting an overpayment adjustment because the patient named is not a provider's patient, attach only a copy of the paid RAD.

Appealing National Correct There is no claims processing system override for National Correct Coding Initiative (NCCI) Coding Initiative (NCCI) edits. Claims that fail federally mandated Denials NCCI edits will be denied and returned to the provider, who must

submit an appeal for reconsideration of payment. Appeals for claims that fail due to NCCI edits are submitted primarily the same way as appeals for claims that fail due to standard Medi-Cal edits. Providers should pay special attention to correct use of modifiers on corrected claims and/or supporting documentation for appeals of NCCI-edit denials.

Additional NCCI appeal information is included in the Part 2 Correct

Coding Initiative: National section. The manual section includes links to a federally maintained Centers for Medicare & Medicaid Centers (CMS) website with NCCI information about denials and appeals.

appeal form 8

2 – Appeal Form Completion March 2011

Correcting NDC/UPN To correct the National Drug Code (NDC) and/or Universal Product Information for Number (UPN) information previously submitted on a claim form, Physician-Administered complete the required fields identified above. Enter the corrected Drug or Disposable Medical NDC/UPN information (Product ID Qualifier, Product ID, Unit of Supply Claims Measure Qualifier or NDC/UPN Quantity) in the Reason for Appeal

field (Box 13). Common Appeal Reasons If filing an appeal for one of the reasons listed in Box 14, mark the

appropriate box and submit the required documentation along with a copy of the claim. This box is for convenience and, if applicable, can be used instead of Box 13. However, all other items must be completed. (See Figure 2 on a following page.)

Signatures Sign and date the bottom of the form. All appeals must be signed by

the provider or an authorized representative. Appeals submitted without a signature will be returned to the provider.

Submission Submit the original Appeal Form and all attachments to the DHCS FI.

appeal form 9

2 – Appeal Form Completion January 2008

Figure 2. Sample Completed Appeal Form (90-1): Common Appeal Reasons.

California Children’s Services (CCS) Program cal child appr Approved Hospitals 1

2 – California Children’s Services (CCS) Program Approved Hospitals June 2004

This section describes the various types of approved California Children’s Services (CCS) hospitals and how a hospital can obtain CCS approval. Hospitals Approved The CCS program assigns various types of approval levels to for CCS hospitals, based on CCS standards and requirements. These

approval levels are as follows. Tertiary Hospital A CCS-approved tertiary hospital is a referral hospital, providing

comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age. The length of stay in a tertiary hospital may exceed 21 days. This approval covers teaching hospitals, children’s and university hospitals, and their major affiliates with approved residency programs in pediatrics and all other major specialties.

Pediatric Community Hospital A CCS-approved pediatric community hospital is a community-based

hospital with licensed pediatric beds, providing services for children from birth up to 21 years of age. The length of stay in an approved pediatric community hospital shall not exceed 21 days, except in the case of care provided in a CCS-approved community or intermediate level Neonatal Intensive Care Unit (NICU).

General Community Hospital A CCS-approved general community hospital is a community-based

hospital without licensed pediatric beds in which care may be provided only for adolescents 14 years of age up to 21 years of age. The length of stay in an approved general community hospital shall not exceed 21 days, except in the case of care provided in a CCS-approved community or intermediate Neonatal Intensive Care Unit (NICU).

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2 – California Children’s Services (CCS) Program Approved Hospitals June 2004

Special Hospital A CCS-approved special hospital is licensed as an acute care hospital and meets one of the following requirements:

• Provides licensed perinatal unit/service and intensive care

newborn nursery (ICNN) service, and meets the CCS NICU standards as a community NICU or intermediate NICU

• Is licensed under special permit for rehabilitation services and meets CCS standards as a rehabilitation facility

• Provides services in a specialized area of medical care and acts as a regional referral center for that specialized type of care (for example, eye surgery, ear surgery, or burn center)

Limited Hospital Limited hospitals are located in rural areas where no community or

tertiary inpatient hospital services are available. These hospitals, which do not have licensed pediatric beds, are capable of providing limited services to children and adolescents for acute short-term conditions for which the expected length of stay does not exceed five days.

Applying for Applications for becoming a CCS-approved hospital may be obtained CCS Approval from the Children’s Medical Services (CMS) Branch at the following address: Children’s Medical Services Branch Provider Services Unit MSC 8100 P.O. Box 997413 Sacramento, CA 95899-7413 Providers may also call one of the following telephone numbers: (916) 322-8702 1-800-PSU-KIDS (1-800-778-5437)

cal child bil California Children’s Services (CCS) Program Billing 1

2 – California Children’s Services (CCS) Program Billing December 2010

This section provides an overview of the California Children’s Services (CCS) program billing guidelines. The CCS Program Billing Guidelines located at the end of this section illustrates the different billing processes for CCS. For claim completion instructions, refer to the CCS Billing Example section in this manual. Billing Overview Providers must be enrolled in the Medi-Cal program and use their

National Provider Identifier (NPI) on all authorized claims for CCS clients, regardless of the client’s CCS program eligibility type. An NPI must be used when billing for CCS/Medi-Cal clients, CCS/Healthy Families Program clients and CCS-only clients.

Service Authorization The CCS program issues providers unique Service Authorization Request (SAR) Number Request (SAR) numbers beginning with a prefix “91” or “97” for

services authorized by CCS. The SAR number must be included on the claim form in the appropriate authorization field. Claims without a SAR number will be denied.

Billing Exception The following billing exception applies to CCS. Special Billing Instructions Providers billing for services rendered to CCS/Medi-Cal clients in at CCS County Office Napa, San Mateo, Santa Barbara, Solano and Yolo counties must

contact the local CCS county office for billing instructions.

cal child bil 2

2 – California Children’s Services (CCS) Program Billing November 2009

Claim Submission and Refer to the Claim Submission and Timeliness Overview section of Timeliness Requirements the Part 1 – Medi-Cal Program and Eligibility manual. This section

details the claim forms used by various providers and the guidelines for submitting those claim forms.

Six-Month Billing Limitation Original (or initial) claims must be received by the Department of

Healthcare Services (DHCS) Fiscal Intermediary (FI) within six months following the month in which services were rendered. Providers submitting claims as an exception to the six-month billing time limit must include a valid delay reason code with each claim. Refer to the Submission and Timeliness Instructions section of the appropriate Part 2 manual for a list of valid delay reason codes. Payments to providers who submit claims after the six-month billing time limit without the required delay reason code will be reduced in accordance with Medi-Cal policy.

CMC Billing Computer Media Claims (CMC) submission is the most efficient

method of billing. Unlike paper claims, these claims already exist on a computer medium. As a result, manual processing is eliminated. CMC submission offers additional efficiency to providers because these claims are submitted faster, entered into the claims processing system faster, and paid faster. For more information, refer to the CMC section of the Part 1 – Medi-Cal Program and Eligibility manual or call the Telephone Service Center (TSC) at 1-800-541-5555.

Denti-Cal CCS/Medi-Cal recipients are eligible for dental services provided by

the Denti-Cal program. Providers should refer to the Denti-Cal Provider Manual for billing instructions.

* “CCS-only” clients are CCS children or CCS/Healthy Families Program children who are not eligible for full-scope, no Share of Cost Medi-Cal.

CCS Program Billing Guidelines For claims submitted with a Service Authorization Request (SAR) number beginning with “91” or “97.”

CCS-Only Client/CCS HF Client * CCS/Medi-Cal Client

Provider Number CMS-1500: Box 33A UB-04: Box 56 Pharmacy 30-1 or 30-4: Box 3 Pharmacy POS: NCPDP specified

National Provider Identifier

Note: Do not use a CGP provider number.



Client ID CMS-1500: Box 1A UB-04: Box 60 Pharmacy 30-1 or 30-4: Box 6 Pharmacy POS: NCPDP specified

Client’s ID number as it appears on the plastic Benefits Identification Card (BIC), paper Medi-

Cal ID card or SAR

Client’s ID number as it appears on the plastic Benefits Identification Card (BIC), paper

Medi-Cal ID card or SAR

Service Authorization Request (SAR) CMS-1500: Box 23 UB-04: Box 63 Pharmacy 30-1: Boxes 27, 46, 65, 84 Pharmacy 30-4: Box 29 Pharmacy POS: NCPDP specified

11-Digit SAR Number (For example: 97123456780)

11-Digit SAR Number (For example: 97123456780)

Where Claims are Submitted for CCS-authorized Services. Medi-Cal/CHDP Fiscal Intermediary (FI)

Medi-Cal/CHDP Fiscal Intermediary (FI) (If a CCS client resides in Napa, San Mateo,

Santa Barbara, Solano or Yolo counties, submit claims per CCS county office policy)

* “CCS-only” clients are CCS children or CCS/Healthy Families Program children who are not eligible for full-scope, no Share of Cost Medi-Cal.

CCS Program Billing Guidelines

For claims submitted without a Service Authorization Number Beginning with “91” or “97”. CCS-Only Client/CCS HF Client * CCS/Medi-Cal Client

Provider Number CMS-1500: Box 33A UB-04: Box 56 Pharmacy 30-1 or 30-4: Box 3 Pharmacy POS: NCPDP specified





Client ID CMS-1500: Box 1A UB-04: Box 60 Pharmacy 30-1 or 30-4: Box 6 Pharmacy POS: NCPDP specified

LEAVE FIELD BLANK Client’s ID number as it appears on the plastic

Benefits Identification Card (BIC) or paper Medi-Cal ID card

Where Claims are Submitted for CCS-authorized Services. Submit Claims per CCS County Office Policy Submit Claims per CCS County Office Policy

California Children’s Services (CCS) Program cal child bil ub Billing Example: UB-04 Claim Form 1

2 – California Children’s Services (CCS) Program Billing Example: UB-04 Claim Form May 2007

The example in this section is to assist providers in California Children’s Services (CCS) program billing on the UB-04 claim form. Refer to the California Children’s Services (CCS) Program section in this manual for policy information. Refer to the UB-04 Completion: Inpatient Services or UB-04 Completion: Outpatient Services sections in the appropriate Part 2 manual for instructions to complete claim fields not explained in the following example. For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section in the appropriate Part 2 manual. For additional billing information, refer to the UB-04 Special Billing Instructions for Inpatient Services, UB-04 Special Billing Instructions for Outpatient Services, UB-04 Submission and Timeliness Instructions, UB-04 Tips for Billing: Inpatient Services, and UB-04 Tips for Billing: Outpatient Services sections in this manual. Note: Although the claim form example in this section uses information and codes appropriate to an

inpatient provider claim, the purpose of the example is to illustrate billing issues of particular interest to CCS providers of either inpatient or outpatient services.

cal child bil ub 2

2 – California Children’s Services (CCS) Program Billing Example: UB-04 Claim Form July 2011

Important Fields for Figure 1. Completing Fields for CCS Claims: Service Authorization CCS Claim Completion Request (SAR), Provider and Client ID Numbers.

This is an example only, based on inpatient services rendered. Providers should note that codes and other information appropriate to outpatient services will differ from this example. An outpatient claim will use codes appropriate to outpatient providers, as well as “O/P Medi-Cal” in line 50. Please adapt to your billing situation. Attachments are not illustrated in this example.

In this example, a medical center is billing for pediatric intensive care services and medical/surgical supplies.

NPI Enter the facility’s appropriate NPI in the NPI field (Box 56).

Note: Enter the facility non-contract hospital NPI when billing for CCS-only and CCS/Healthy Families clients.

Insured’s Unique ID Enter the client’s identification number in the Insured’s Unique ID field

(Box 60) as it appears on the plastic Benefits Identification Card (BIC) or paper Medi-Cal ID card.

Note: For providers billing without a SAR number with prefix “91” or

“97” for CCS-only or CCS/Healthy Families clients, leave this field blank.

Treatment Authorization Enter the 11-digit SAR number in the Treatment Authorization Codes Codes field (Box 63).

Note: For providers billing without a SAR number with prefix “91” or “97”, leave this field blank.

Referring Physician ID Enter the NPI of the referring physician in the Attending field (Box 76),

if applicable.

Note: If the referring physician initiated the SAR, then enter the referring physician’s NPI. Otherwise, if the rendering physician initiated the SAR, this field must be left blank.

cal child bil ub 3

2 – California Children’s Services (CCS) Program Billing Example: UB-04 Claim Form May 2007

Figure 1. Completing Fields for CCS Claims: SAR, Provider and Client ID Numbers.

California Children’s Services (CCS) Program cal child county County Office Directory 1

2 – California Children’s Services (CCS) Program County Office Directory June 2004

This section includes California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) state office locations and a CCS county office directory. CCS County Office Directory The following CCS directory identifies the CCS county offices as

dependent or independent, and the regional office responsible for the dependent county. The directory is important for determining whether to submit a Service Authorization Request (SAR) to the CCS county office or the CCS state regional office.

The following guidelines may be helpful for selecting the correct office:

• For questions about eligibility, prior authorization and submitting claims in independent counties, please contact the CCS independent county office.

• For residential eligibility or financial questions in dependent counties, please contact the CCS dependent county office.

• For medical eligibility questions in dependent counties, please contact the appropriate CCS state regional office.

• For questions about prior authorization or submitting claims in dependent counties, contact the appropriate CCS state regional office.

cal child county 2

2 – California Children’s Services (CCS) Program County Office Directory May 2009

State Office Locations CCS Sacramento Regional Office MS 8100 P.O. Box 997413 Sacramento, CA 95899-7413 Main (916) 327-3100 Fax (916) 327-0998 CCS Southern California Regional Office 311 South Spring Street, Suite 01-11 Los Angeles, CA 90013 Main (213) 897-3571 Fax (213) 897-3501 or (213) 897-2882 CCS Northern California Region Oakland Office 1515 Clay Street, Suite 401 Oakland, CA 94612 Main (510) 286-0757 Fax (510) 286-0743 Genetically Handicapped Persons Program (GHPP) MS 8105 P.O. Box 997413 Sacramento, CA 95899-7413 Main (916) 327-0470 Fax (916) 327-1112 Toll Free: 1-800-639-0597

cal child county 3

2 – California Children’s Services (CCS) Program County Office Directory June 2004

County Office Address Telephone FAX Dependent/ Independent

Regional Office

Alameda 1000 Broadway, Suite 500 Oakland, CA 94607

(510) 208-5970 (510) 267-3270 Independent San Francisco

Alpine 75-B Diamond Valley Road Markleeville, CA 96120

(530) 694-2146 (530) 694-2252 Dependent Sacramento

Amador 1003 Broadway, Suite 101 Jackson, CA 95642


Butte 1370 Ridgewood Drive, Suite 22 Chico, CA 95379

(530) 895-6546 (530) 895-6557 Independent Sacramento

Calaveras 891 Mountain Ranch Road San Andreas, CA 95249


Colusa 251 East Webster Street Colusa, CA 95932


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2 – California Children’s Services (CCS) Program County Office Directory November 2004


Regional Office

Contra Costa 597 Center Avenue, Suite 110 Martinez, CA 94553


Del Norte 880 Northcrest Drive Crescent City, CA 95531

(707) 464-3191 (707) 465-1783 Dependent San Francisco

El Dorado 929 Spring Street Placerville, CA 95667


Fresno 1221 Fulton Mall Fresno, CA 93721


Glenn 240 North Villa Avenue Willows, CA 95988


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2 – California Children’s Services (CCS) Program County Office Directory February 2008


Regional Office

Humboldt 317 Second Street Eureka, CA 95501-0425


Imperial 935 Broadway El Centro, CA 92243

(760) 482-4434 (760) 482-4664 Dependent Southern California

Inyo 207-A West South Street Bishop, CA 93514


Kern 1800 Mount Vernon Avenue, 2nd Floor Bakersfield, CA 93306

(661) 868-0531 (661) 868-0216 Independent Southern California

Kings 330 Campus Drive Hanford, CA 93230


Lake 922 Bevins Court Lakeport, CA 95453


Lassen 1445 B Paul Bunyan Road Susanville, CA 96130


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Regional Office

Los Angeles 9320 Telstar Avenue, Suite 226 El Monte, CA 91731

1-800-288-4584 1-800-924-1154 Independent Southern California

Madera 14215 Road 28 Madera, CA 93638


Marin 555 Northgate Drive, Suite B San Rafael, CA 94903


Mariposa 4988 Eleventh Street Mariposa, CA 95338


Mendocino 1120 South Dora Street Ukiah, CA 95482-8333


Merced 260 East 15th Street Merced, CA 95340


Modoc 441 North Main Street Alturas, CA 96101


Mono 437 Old Mammoth Road, Suite Q Mammoth Lakes, CA 93546


Monterey 1441 Constitution Boulevard, Building 400, Suite 200 Salinas, CA 93906


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2 – California Children’s Services (CCS) Program County Office Directory February 2008


Regional Office

Napa 2261 Elm Street, Building G Napa, CA 94559


Nevada 10433 Willow Valley Road, Suite B Nevada City, CA 95959


Orange 200 West Santa Ana Boulevard, Suite 100 Santa Ana, CA 93701


Placer 11484 B Avenue Auburn, CA 95603


Plumas 270 County Hospital Road Quincy, CA 95971


Riverside 10769 Hole Avenue, Suite 220 Riverside, CA 92505


Sacramento 9616 Micron Avenue, Suite 640 Sacramento, CA 95827


San Benito 439 Fourth Street Hollister, CA 95023


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Regional Office

San Bernardino 155 Carousel Mall San Bernardino, CA 92415


San Diego 6160 Mission Gorge Road San Diego, CA 92120


San Francisco 30 Van Ness Avenue, Suite 210 San Francisco, CA 94102


San Joaquin 2233 Grand Canal Boulevard, Suite 105 Stockton, CA 95207


San Luis Obispo 2156 Sierra Way San Luis Obispo, CA 93401


San Mateo 225 37th Avenue San Mateo, CA 94403


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Regional Office

Santa Barbara 1111 Chapala Street, Suite 200 Santa Barbara, CA 93101


Santa Clara 720 Empey Way San Jose, CA 95128


Santa Cruz 12 West Beach Street Watsonville, CA 95076


Shasta 3499 Hiatt Drive Redding, CA 96033


Sierra 202 Front Street Loyalton, CA 96118


Siskiyou 806 South Main Street Yreka, CA 96097


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Regional Office

Solano 275 Beck Avenue, MS 5-230 Fairfield, CA 94533


Sonoma 625 Fifth Street Santa Rosa, CA 95404


Stanislaus 830 Scenic Drive, Suite D Modesto, CA 95350


Sutter 1445 Veterans Memorial Circle Yuba City, CA 95993


Tehama 1860 Walnut Street, Building C Red Bluff, CA 96080


Trinity 1 Industrial Park Way Weaverville, CA 96093


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Regional Office

Tulare 115 East Tulare Avenue Tulare, CA 93274


Tuolumne 20111 Cedar Road North Sonora, CA 95370


Ventura 2240 East Gonzales Road, Suite 260 Oxnard, CA 93036


Yolo 825 East Street, Suite 302 Woodland, CA 95776


Yuba 6000 Lindhurst Avenue, Suite 601-B Marysville, CA 95901


California Children’s Services (CCS) Program cal child elig Eligibility 1

2 – California Children’s Services (CCS) Program Eligibility June 2004

This section explains the specific eligibility requirements potential CCS clients must meet in order to participate in the California Children’s Services (CCS) program. Eligibility Requirements Applicants must meet age, residence, income and medical eligibility

requirements to participate in the CCS program, as follows. Age Birth up to 21 years of age Residence The parent(s) or legal guardian of the applicant, or an applicant over

18 years of age, must be a resident of a California county, and be a resident of the county in which the application is made.

Income Income eligibility is based on the family’s most recent tax year as

calculated for California State income tax purposes. The family of an applicant who is not enrolled in full-scope Medi-Cal or who is not a Healthy Families (HF) Program subscriber must have an adjusted gross income of $40,000 or less. Applicants in families with higher incomes may still be eligible for CCS services if the family’s estimated out-of-pocket expenses for the applicant’s CCS-eligible medical condition are expected to exceed 20 percent of the family’s adjusted gross income in the year of eligibility determination or annual redetermination.

Medical Applicants must meet one of the requirements described in this

section under “Medical Eligibility Criteria.”

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Eligibility Period CCS program eligibility is for a period of up to 365 days, and may be less if the client’s eligibility status changes. Examples of such a status change is a client moving out of California, losing Medi-Cal or HF coverage, failure to complete the CCS application process, or a change in a medically eligible condition. CCS will not pay for services provided prior to the date of a client’s eligibility.

Annual redetermination of eligibility for the CCS program is conducted

during the first month following each 12-month period of eligibility. If a client has been and continues to be eligible for full-scope Medi-Cal, the annual redetermination will consist of verification of the client’s current Medi-Cal status and the continuing presence of a CCS-eligible medical condition. If a client has been and continues to be a HF subscriber, the annual redetermination will consist of verification of the client’s current HF eligibility and the continuing presence of a CCS-eligible medical condition.

Note: Recertification may be conducted prior to the annual expiration

date to avoid lapsing coverage and to ensure services are reimbursed.

Benefits Identification CCS clients enrolled in the CCS program are issued a Benefits Card (BIC) Identification Card (BIC). Possession of a BIC is not proof of CCS

eligibility because it is a permanent form of identification and is retained by the recipient even if he or she is not eligible for the current month. A BIC allows providers to determine CCS eligibility using a Point of Service (POS) device. If a CCS client also has Medi-Cal or HF eligibility, CCS eligibility will be displayed along with the Medi-Cal or HF eligibility. Note: CCS-Only and CCS/HF Program clients residing in

Los Angeles, Orange and Sacramento counties are not issued a BIC.

Children eligible for CCS will be identified by aid codes unique to the CCS program. For aid codes and associated messages, refer to the Aid Codes Master Chart section in the Part 1 – Medi-Cal Program and Eligibility provider manual.

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Medical Eligibility Criteria Medical eligibility for the CCS program, as specified in the California Code of Regulations (CCR), Title 22, Article 1, Sections 41811 through 41876, is determined by the CCS program medical consultant or designee through the review of medical records or other medical information that document the applicant’s medical history, results of a physical examination by a physician, laboratory test results, radiologic findings, or other tests or examinations that support the diagnosis of the eligible conditions.

The following is a summary of CCS-eligible medical conditions. This

summary is solely to assist providers in understanding the medical eligibility criteria of the CCS program. The summary is not an authoritative statement of, and should not be cited as, authority for any decision, determinations or interpretations of the CCS program. Please refer to the regulations cited above for a definitive description of CCS medical eligibility.

Infectious Diseases In general, an infectious disease is a CCS-eligible medical condition

when it:

• Involves the central nervous system and produces disabilities requiring surgical and/or rehabilitation services

• Involves bone • Involves eyes and leads to blindness • Is congenitally acquired and for which postnatal treatment is

necessary and appropriate Neoplasms In general, a neoplasm is a CCS-eligible medical condition when it:

• Involves the central nervous system and produces disabilities requiring surgical and/or rehabilitation services

• Involves bone • Involves eyes and leads to blindness • Is congenitally acquired and for which postnatal treatment is

necessary and appropriate

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Endocrine, Nutritional and In general, endocrine, nutritional and metabolic diseases, and immune Metabolic Diseases and disorders are CCS-eligible medical conditions. Examples of these Immune Disorders conditions are diseases of the pituitary, thyroid, parathyroid, adrenal,

pancreas, ovaries and testes, growth hormone deficiency, diabetes mellitus, diseases due to congenital or acquired immunologic deficiency manifested by life-threatening complications, various inborn errors of metabolism, and cystic fibrosis.

Nutritional disorders such as failure to thrive and exogenous obesity

are not CCS-eligible medical conditions. Diseases of Blood and In general, diseases of blood and blood-forming organs are Blood-Forming Organs CCS-eligible medical conditions. Common examples of eligible

conditions are sickle-cell anemia and aplastic anemia. Iron or vitamin deficiency anemias are eligible only when life-threatening complications are present.

Mental Disorders and CCS applicants with mental disorders or mental retardation, whose Mental Retardation application is based solely on such disorders, are not medically

eligible for the CCS program. Diseases of the Diseases of the nervous system are, in general, medically eligible Nervous System conditions when they produce physical disability (for example, paresis,

paralysis or ataxia) that significantly impair daily function. Idiopathic epilepsy is eligible when the seizures are uncontrolled, as

defined in the CCR regulations. Treatment of seizures due to underlying organic disease (for example, brain tumor, cerebral palsy or inborn errors of metabolism) is based on the eligibility of the underlying disease.

Specific conditions not medically eligible are those that are self-

limiting. These include acute neuritis, neuralgia, and meningitis that does not produce sequelae or physical disability. Learning disabilities are not eligible medical conditions.

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Diseases of the Eye Strabismus is a CCS-eligible medical condition when surgery is required. Chronic infections or diseases of the eye are medically eligible when they produce visual impairment and/or require complex management or surgery.

Diseases of the Ear and Diseases of the ear and mastoid process that are medically eligible Mastoid Process conditions include hearing loss as defined in the CCR regulations;

perforation of the tympanic membrane requiring tympanoplasty; mastoiditis and cholesteatoma.

Diseases of the In general, diseases of the circulatory system that are CCS-eligible Circulatory System medical conditions involve the heart, blood vessels, and

lymphatic system. Diseases of the Lower respiratory tract conditions are medically eligible if they are Respiratory System chronic, cause significant disability and respiratory obstruction, or

complicate the management of a CCS-eligible medical condition.

Chronic lung disease of infancy and immunologic origin are medically eligible conditions, as defined by CCR regulations.

Diseases of the Diseases of the liver, chronic inflammatory disease of the Digestive System gastrointestinal (GI) tract, most congenital abnormalities of the GI

system, and gastroesophageal reflux are medically eligible conditions, as defined by CCR regulations.

Malocclusion is medically eligible when severe impairment of occlusal function is present and is subject to CCS screening and acceptance for care.

Diseases of the Chronic genitourinary conditions and renal failure are medically Genitourinary System eligible conditions. Acute conditions are medically eligible when

complications are present.

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Diseases of the Skin and Diseases of the skin and subcutaneous tissues are CCS-eligible Subcutaneous Tissues medical conditions if they are disfiguring, disabling and require plastic

or reconstructive surgery and/or prolonged and frequent multidisciplinary management.

Diseases of the Chronic diseases of the musculoskeletal system and connective tissue Musculoskeletal System and are medically eligible conditions. Minor orthopedic conditions such as Connective Tissue toeing-in, knock knee and flat feet are not medically eligible.

However, these conditions may be medically eligible if expensive bracing, multiple casting, and/or surgery is required.

Congenital Anomalies Congenital anomalies of the various systems are medically eligible

conditions if they limit a body function, are disabling, disfiguring, or are amenable to cure, correction or amelioration, as defined by CCR regulations.

Perinatal Morbidity CCS authorizes services in CCS-approved Neonatal Intensive Care Units (NICUs) for neonates who have a CCS-eligible medical

condition and require NICU care because of that condition. Critically ill neonates who do not have an identified CCS-eligible

medical condition are medically eligible for CCS when they require one or more of the following services in a CCS-approved NICU:

• Invasive or non-invasive positive ventilatory assistance • Supplemental oxygen concentration by hood of greater than or equal

to 40 percent • Maintenance of an umbilical artery (UA) or peripheral arterial catheter

(PAC) for medically necessary indications, such as monitoring blood pressure or blood gases

• Maintenance of an umbilical venous catheter or other central venous catheter for medically necessary indications, such as pressure monitoring or cardiovascular drug infusion

• Maintenance of a peripheral line for intravenous pharmacological support of the cardiovascular system

• Central or peripheral hyperalimentation • Chest tube

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Neonates and infants who do not have an identified CCS-eligible medical condition are medically eligible for CCS when they require two or more of the following services in a CCS-approved NICU:

• Supplemental inspired oxygen • Maintenance of a peripheral intravenous line for administration of

intravenous fluids, blood, blood products, or medications other than those used in support of the cardiovascular system

• Pharmacological treatment for apnea and/or bradycardia episodes • Tube feedings

Accidents, Poisonings, CCS-eligible medical conditions may include: Pharmacological Violence and Immunization Reactions

• Injuries of the central or peripheral nervous system and vital organs if they can result in permanent disability or death

• Fractures of the skull, spine, pelvis or femur which when untreated would result in permanent loss of function or death

• Burns, foreign bodies, ingestion of drugs or poisons, lead poisoning and snake bites may be eligible

California Children’s Services (CCS) Program cal child med Medical Therapy Program 1

2 – California Children’s Services (CCS) Program Medical Therapy Program June 2004

This section explains the eligibility requirements applicants must meet to participate in the California Children’s Services (CCS) Medical Therapy Program (MTP). Program Description MTP is a component of the CCS program. Operating from medical

therapy units located in public schools, MTP provides physical therapy, occupational therapy and physician consultation for children with specific eligible medical conditions described in this section.

Clients who are eligible for MTP only, and not for the general CCS

program, are provided only medically necessary physical therapy, occupational therapy, and physician consultations in a medical therapy unit.

Eligibility Requirements Applicants must meet age, residence and medical eligibility

requirements to participate in MTP, as follows. Age Applicants may be eligible for MTP from birth up to 21 years of age. Residence Applicants must currently reside in the state of California and/or be

enrolled in a state of California public school. Income There is no financial eligibility requirement for MTP. Medical Applicants must meet the medical eligibility criteria detailed in

this section.

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2 – California Children’s Services (CCS) Program Medical Therapy Program June 2004

MTP Medical Eligibility CCS applicants with at least one of the following conditions are Criteria medically eligible for participation in MTP.

• Cerebral palsy, a motor disorder with onset in early childhood resulting from a non-progressive lesion in the brain, manifested by the presence of one or more of the following:

− Rigidity or spasticity

− Hypotonia, with normal or increased deep tendon reflexes, and exaggeration of or persistence of primitive reflexes beyond the normal age range

− Involuntary movements that are described as athetoid, choreoid or dystonic

− Ataxia manifested by incoordination of voluntary movement, dysdiadochokinesia, intention tremor, reeling or shaking of trunk and head, staggering or stumbling, and broad-based gait

• Neuromuscular conditions that produce muscle weakness and atrophy, such as poliomyelitis, myasthenias and muscular dystrophies

• Chronic musculoskeletal and connective tissue diseases or deformities such as osteogenesis imperfecta, arthrogryposis, rheumatoid arthritis, amputations and contractures resulting from burns

• Other conditions manifesting the findings listed above such as ataxias, degenerative neurological disease or other intracranial processes

CCS applicants 3 years of age or younger are eligible when two or

more of the following neurological findings are present:

• Exaggerations of or persistence of primitive reflexes beyond the normal age (corrected for prematurity)

• Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater

• Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into an abnormal position

• Hypotonicity, with normal or increased DTRs, in infants below one year of age (infants above one year must meet the cerebral palsy criteria described above)

• Asymmetry of motor findings of trunk or extremities MTP Referral The process for referring applicants to MTP follows the same guidelines as general CCS program referrals. Please see the

California Children’s Services (CCS) Program Referrals section in this manual for further information.

California Children’s Services (CCS) Program cal child panel Provider Paneling 1

2 – California Children’s Services (CCS) Program Provider Paneling June 2004

This section describes the paneling requirements providers must meet to participate as a California Children’s Services (CCS) program provider. Provider Paneling The following providers must be paneled by CCS in order to treat Requirement clients with a CCS-eligible medical condition:

• Physicians • Podiatrists • Audiologists • Dietitians • Marriage Family Therapists * • Occupational Therapists • Orthotists • Pediatric Nurse Practitioners * • Physical Therapists • Prosthetists • Psychologists • Registered Nurses * • Respiratory Therapists * • Social Workers • Speech Language Pathologists

* Provider type is subject to program participation limitations. Refer to the individual provider type description in this section for more information.

Provider types not listed above do not need to be paneled by the CCS program to treat CCS clients.

cal child panel 2

2 – California Children’s Services (CCS) Program Provider Paneling February 2008

Panel Applications The application for becoming paneled by CCS has two versions: A California Children’s Services (CCS) Program Individual Provider

Paneling Application for Physicians and Podiatrists (form DHCS 4514) and a California Children’s Services (CCS) Program Individual Provider Paneling Application for Allied Health Care Professionals (form DHCS 4515). Copies of these forms and instructions for completing them are found at the end of this section. These forms may also be obtained by:

• Visiting the CCS Web site at www.dhcs.ca.gov/services/ccs/pages/default.aspx and clicking “Forms”

• Visiting the Medi-Cal Web site at www.medi-cal.ca.gov and clicking “Forms” and scrolling down to “California Children’s Services (CCS)”

• Calling the Provider Services Unit at (916) 322-8702 and requesting an application

• Writing the Provider Services Unit and requesting an application at the following address:

Children’s Medical Services Branch Provider Services Unit MSC 8100 P.O. Box 997413 Sacramento, CA 95899-7413

Completed panel applications should be sent to the above address. National Provider All providers applying for CCS paneling must have a National Identifier Required Provider Identifier (NPI).

cal child panel 3


Physician Paneling Physicians may be paneled with full or provisional approval status, Categories described as follows. Full Approval Physician applicants who meet all criteria required for paneling,

including certification by the American Board of Medical Specialties, will be given full panel approval.

Provisional Approval If the physician is board eligible for the American Board of Medical

Specialties, provisional paneling status will be given to the physician for three years upon completion of residency or fellowship training. Upon successful completion of the board examination, the physician must provide an American Board of Medical Specialties certificate immediately to the following Children’s Medical Services (CMS) Branch address:

Children’s Medical Services Branch Provider Services Unit MSC 8100 P.O. Box 997413 Sacramento, CA 95899-7413

Upon receipt of the certificate by CMS, the provisional panel approval status will be changed to full approval.

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2 – California Children’s Services (CCS) Program Provider Paneling May 2007

Preferred Provider Status Physicians may qualify as a Medi-Cal provider under “preferred For Physicians Applying provider status,” per Welfare and Institutions Code (W&I Code), For Medi-Cal Enrollment Section 14043.26(c). To be considered for preferred provider status,

the physician must:

• Hold a current license as a physician and surgeon issued by the Medical Board of California or the Osteopathic Medical Board of California. The license must not have been revoked, whether stayed or not, suspended, placed on probation, or subjected to other limitations. The physician must include a copy of her/his medical license with the panel application.

• Be a current faculty member of a teaching hospital or a children’s hospital as defined in W&I Code, Section 10727, accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association (AOA) Healthcare Facilities Accreditation Program (HFAP).

• Be credentialed by a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975.

• Be credentialed by a County Organized Health System (COHS), or be a current member in good standing of a group credentialed by a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975.

• Have full, current, unrevoked, unsuspended privileges at a general acute care hospital accredited by the JCAHO or HFAP.

• Have no adverse entries in the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank.

If the application is complete with all required attachments, and without omissions or errors, the application will be processed within 90 days of the application receipt date. Complete instructions for submitting a required cover letter that verifies a provider’s qualifications for preferred provider status may be obtained by visiting the Medi-Cal Web site at www.medi-cal.ca.gov, clicking “Provider Enrollment,” then “Preferred Provider Status.”

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Physician Physicians providing medical services to CCS applicants or clients Requirements must be:

• Licensed as a physician and surgeon by the Medical Board of California or by the Osteopathic Medical Board of California

• Certified by the American Board of Medical Specialties Physicians who are not board certified, but are eligible for the

certifying examination by meeting the training and experience requirements for certification, may participate in the CCS program for not more than three years after completion of residency or fellowship training.

Family Practice Physician Family practice physicians providing medical services to CCS Requirements clients must:

• Be currently licensed as a physician by the California Board of Medical Quality Assurance

• Be certified by the American Board of Family Practice • Have expertise in the care of physically handicapped children

with severe and complex medical conditions • Have documented experience treating children with severe and

complex medical conditions for at least five years, or have treated 100 or more such children. Documentation must be provided.

Note: Family practice physicians certified by the American

Board of Family Practice and also certified in the subspecialty of Adolescent Medicine may submit a panel application for review, even if the requirement stated in the last bullet above is not entirely met.

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Providing a Medical Home Children with Special Health Care Needs require a “medical home.” A medical home is defined as the child’s physician providing comprehensive, coordinated and continuous care in order to facilitate access to all of the medical and non-medical services needed to help the client and the client’s family achieve maximum potential. Generally, the primary care pediatrician in the client’s community provides this medical home. The medical home physician provides compassionate and culturally competent care. Recognizing that the family is the principal caregiver and a partner in the health care team, the physician shares information with the family on an ongoing basis.

Medical Home Requirements The medical home community physician is responsible for meeting the

following requirements for children receiving care from 1.) CCS-paneled specialists, 2.) CCS-approved Special Care Centers (SCCs) or 3.) Medical Therapy Programs (MTPs):

• Be authorized by CCS for health care services related to the

client’s CCS-eligible medical condition • Provide treatment for the client’s CCS-eligible medical

condition, according to the plan of care developed by number 1, 2 or 3 above

• Coordinate treatment for the client’s CCS-eligible medical condition and take direction for the client’s care from number 1, 2 or 3 above

• Communicate with number 1, 2 or 3 above about changes in the client’s medical condition

• Maintain medical records that identify the client’s special health care needs, as well as the resources and services used for implementing the plan of care established by number 1, 2 or 3 above

• Participate in transition planning to adulthood

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Medical Home Resources Medical home information, links, tools and resources are as follows:

• American Academy of Pediatrics National Center of Medical Home Initiatives for Children with Special Needs at www.medicalhomeinfo.org

• Practicing Comprehensive Care: A Physician’s Operations Manual for Implementing a Medical Home for Children with Special Health Care Needs. Institute for Community Inclusion, Children’s Hospital, Boston, MA 2000, available on the Internet at www.communityinclusion.org

Podiatrist Requirements Podiatrists must be licensed to practice podiatric medicine by the

California Board of Podiatric Medicine, be certified by the American Board of Podiatric Surgery or the American Board of Podiatric Orthopaedics, and have documented experience in treating children with CCS-eligible medical conditions for at least five years, or have treated 100 or more such children.

Audiologist Requirements Audiologists must be licensed as such by the California

Speech-Language Pathology and Audiology Board. They must have two years of clinical experience providing audiology services, one of which must have been with infants, children and adolescents. The experience may include the clinical fellowship year.

cal child panel 8


Dietitian Requirements Dietitians must be registered by the Commission on Dietetic Registration of the American Dietetic Association, and have at least two years, or the equivalent, of full time clinical nutrition therapy experience as part of a multidisciplinary team providing nutrition assessment and counseling for acute or chronically ill patients. One of the required years of clinical experience must have been providing services to infants, children, and adolescents with CCS-eligible medical conditions.

Occupational Therapist Occupational therapists must meet the following requirements: Requirements

• Be a graduate of an occupational therapy curriculum accredited by the American Occupational Therapy Association, the World Federation of Occupational Therapists or another nationally recognized accrediting agency

• Be certified by the National Board for Certification in Occupational Therapy

• Have at least one year of experience, beyond internship (that is, the fieldwork performed following completion of curriculum requirements), providing occupational therapy to infants, children and adolescents who have CCS-eligible medical conditions

Orthotist and Prosthetist Orthotists and prosthetists must be certified by the American Board for Requirements Certification in Orthotics and Prosthetics or the Board for

Orthotist/Prosthetist Certification.

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Pediatric Nurse Participation in the CCS program as a Pediatric Nurse Practitioner Practitioner Requirements (PNP) is limited to serving as a designated core team member of a

CCS-approved multidisciplinary, multispecialty team in an outpatient department of a CCS-approved hospital.

PNPs must meet the following requirements:

• Be certified as a nurse practitioner by the California Board of Registered Nursing

• Be certified as a PNP by the National Certification Board of Pediatric Nurse Practitioners and Nurses or the American Nurses Association

• Have a minimum of two years of experience as a PNP, including providing services to children with CCS-eligible medical conditions. The required experience may be obtained prior to being certified as a PNP. In such cases, the individual must have been, for a minimum of two years, a designated registered nurse core team member of a multidisciplinary, multispecialty team in an outpatient department of a CCS-approved acute care hospital.

Physical Therapist Physical therapists must be licensed as such by the Physical Therapy Requirements Board of California and must have one year of experience, beyond

internship (that is, the fieldwork performed following completion of curriculum requirements) providing physical therapy to infants, children and adolescents with CCS-eligible medical conditions.

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Psychologist Requirements Psychologists must be licensed as such by the California Board of Psychology or credentialed by the California State Board of Education or Commission on Teacher Credentialing, and have a minimum of two years of clinical experience in which at least 50 percent of the individual’s time has been spent counseling or testing children who have mental disorders, developmental disabilities or CCS-eligible medical conditions.

Registered Nurse Registered nurses must be licensed as such by the California Board of Requirements Registered Nursing and be designated as a core team member of an

outpatient clinic’s multidisciplinary, multispecialty team, providing care to children with CCS-eligible medical conditions. In addition, the registered nurse must have:

• A minimum preparation of a baccalaureate degree in nursing

from a program having requirements equal to or greater than a baccalaureate level nursing program approved by the California Board of Registered Nursing

• A minimum of two years of clinical nursing experience of which one year must be in pediatrics, unless the outpatient clinic had a separate adult program only, in which case, the pediatric requirement may be waived

• Responsibilities in an outpatient clinic that include, but are not limited to, nursing assessment and intervention; coordination of patient’s care between hospitalizations, outpatient services, and community agencies; participation in team conferences; quality improvement programs; and in-service programs

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Respiratory Care Participation in the CCS program as a respiratory care practitioner Practitioner Requirements is limited to serving as a designated core team member of a

multidisciplinary, multispecialty team in an outpatient department or clinic of an acute care hospital that provides services to children with CCS-eligible medical conditions. A respiratory care practitioner may also be referred to as a respiratory therapist or inhalation therapist.

A respiratory care practitioner must meet the following requirements:

• Be licensed by the Respiratory Care Board of California • Have a current Registered Respiratory Therapist credential

issued by the National Board for Respiratory Care • Have a minimum of two years of respiratory care experience of

which one year must be in pediatrics • Currently be a designated core team member of a

multidisciplinary, multispecialty team in a hospital approved for CCS

• Have responsibilities in the hospital’s outpatient clinic, including individualized diagnostic and therapeutic respiratory care procedures and patient education related to the implementation of the team care plan for outpatient services

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Social Worker Social workers must be licensed as clinical social workers by the Requirements California Board of Behavioral Science Examiners or have a master’s

degree in social work from a school accredited by the Council on Social Work Education and have at least 7,500 hours or five years of full time social work experience.

Individuals who do not meet the requirements above may be given

CCS panel approval by including with their panel application a letter with evidence of the following:

• The applicant will be supervised by someone who meets the

requirements described above • The level of supervision received will be a minimum of weekly

supervision for those with less than two years experience, or a minimum of monthly supervision for social workers with more than two years of experience

The letter must be signed by the social worker’s supervisor or social

work department director and attached to the panel application. Speech-Language Speech-language pathologists must be licensed as such by the Pathologist Requirements California Speech-Language Pathology and Audiology Board and

have two years of clinical experience providing speech-language pathology services, one year of which must have been with infants, children and adolescents with CCS-eligible medical conditions. The required experience may include the clinical fellowship year.

California Children’s Services (CCS) Program cal child ref Referrals 1

2 – California Children’s Services (CCS) Program Referrals February 2008

This section describes guidelines for referring potential applicants to the California Children’s Services (CCS) program. CCS Referral A CCS referral is a request directed to the CCS program to authorize

medical services for an applicant who meets the following conditions.

• The applicant is younger than 21 years of age. • The applicant is not currently a CCS program recipient. • The applicant has, or is suspected of having, a CCS-eligible

medical condition. A referral may originate from any source, including health care providers, parents, legal guardians, school nurses, regional center

counselors, or other interested parties. CCS Referral A CCS referral must include the following information Requirements about the applicant:

• Date of birth (applicant must be from birth up to 21 years of age)

• Address • Telephone number • First and last name of the applicant’s parent(s)

or legal guardian(s) • Statement of services requested • Name and address of the individual, provider or agency

requesting authorization for CCS services The CCS program notifies the potential applicant of a CCS referral

and provides the applicant with the opportunity to complete an Application to Determine CCS Program Eligibility (form DHCS 4480).

cal child ref 2

2 – California Children’s Services (CCS) Program Referrals February 2008

CCS Referral Formats A CCS referral may be submitted using any of the following formats:

• A New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488)

• Medical report or a letter with a specific request for services from CCS (A medical report or miscellaneous correspondence about a potential applicant that does not explicitly state services requested from CCS is not considered a formal CCS referral)

• Written request by a parent or legal guardian • Information provided by telephone or in person at a CCS

county office Where to Submit The CCS referral is submitted to the CCS county office where the CCS Referrals applicant resides. The CCS county office independently, or in

conjunction with a state regional office, determines the applicant’s program eligibility and authorizes medically necessary health care services.

For a complete list of CCS county and state regional offices, refer to

the California Children’s Services (CCS) Program County Office Directory section in this manual.

cal child ref 3

2 – California Children’s Services (CCS) Program Referrals June 2004

CCS Program Application CCS referrals should be made to the CCS program as early as Requirements possible because CCS does not pay for health care services provided

before the date of referral, unless the CCS client is a full-scope Medi-Cal recipient.

The applicant or applicant’s parent or legal guardian is required to

complete an Application to Determine CCS Program Eligibility form. CCS reviews the form and determines whether the applicant meets the medical, residential, age and income eligibility requirements of the CCS program.

For applicants who are recipients of full-scope Medi-Cal or are

enrolled in a Healthy Families (HF) Program plan, CCS may authorize services requested on a CCS referral prior to the completion of the application process if the following criteria are met:

• CCS has received sufficient information to confirm the

presence of a CCS-eligible medical condition

• The requested services are determined to be medically necessary

• The requested services are included in the applicant’s full-scope Medi-Cal or HF Program plan benefits

The applicant or applicant’s parent or legal guardian must complete

the application process in order to be fully enrolled in the CCS program.

California Children’s Services (CCS) Program cal child sar Service Authorization Request (SAR) 1

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) February 2008

This section includes instructions for submitting a Service Authorization Request (SAR) to the California Children’s Services (CCS) program. SAR Overview The CCS program requires authorization for health care services related to a client’s CCS-eligible medical condition. Providers must

submit a SAR to a CCS county or state regional office, except in an emergency. Only active Medi-Cal providers may receive authorization to provide CCS program services. Services may be authorized for varying lengths of time during the CCS client’s eligibility period.

Providers may request services for CCS clients using one of the following SAR forms located at the end of this section:

• New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488)

• Established CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4509)

• CCS/GHPP Discharge Planning Service Authorization Request (SAR) (form DHCS 4489)

The forms are also available at both the Medi-Cal Web site at www.medi-cal.ca.gov and the CCS Web site at www.dhcs.ca.gov/services/ccs/pages/default.aspx. The CCS program case manages and authorizes services for children with CCS-eligible medical conditions who are enrolled in the CCS program, Healthy Families (HF) Program or Medi-Cal program. Only services related to a CCS-eligible medical condition may be authorized and reimbursed by the CCS program.

Physician SAR for A SAR number authorized to a physician may be used for Rendering Provider reimbursement by other health care providers from whom the

physician has requested services, such as laboratory, pharmacy or radiology providers. The rendering provider will use a physician’s SAR number and bill with the authorized physician’s provider number indicated as a referring provider.

Note: This does not apply to SARs issued to CCS Special Care

Centers (SCCs). For more information about SCCs, refer to the California Children’s Services (CCS) Program Special Care Centers section in this manual.

cal child sar 2


Where to Submit SARs Providers should refer to the California Children’s Services (CCS) Program County Office Directory section in this manual for the appropriate county or state office to submit SARs. If a child resides in an independent county, submit a SAR to the CCS county office. If a child resides in a dependent county, submit a SAR to the appropriate CCS state regional office based on the child’s county of residence.

Providers may fax, mail or hand deliver SARs to the appropriate CCS county or state regional office. After CCS review, providers will receive a hard copy authorization approval or denial for each submitted SAR.

Types of SAR Forms New Referral The New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488) is used when referring an applicant suspected of having a CCS-eligible medical condition to the CCS

program. The applicant’s case may be opened by CCS for diagnostic, treatment or Medical Therapy Program (MTP) services. For more information, refer to the California Children’s Services (CCS) Program Referrals section in this manual.

Established Client The Established CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4509) is used when requesting service authorization for an established CCS client currently enrolled in the

CCS program. The Established Client SAR form does not require as much information about the client as the New Referral SAR form. Providers are to request specific services related to the treatment of the CCS-eligible medical condition when submitting this SAR form.

Discharge Planning The CCS/GHPP Discharge Planning Service Authorization Request (SAR) (form DHCS 4489) is used when requesting specific services for a CCS client who is discharged from an inpatient hospital stay.

The requested services may include, but are not limited to, Home Health Agencies (HHA), Durable Medical Equipment (DME), medical supplies, community services and other medically necessary services related to the CCS-eligible medical condition.

cal child sar 3

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) August 2008

The following is the minimum information required for submitting a Discharge Planning SAR:

• Provider name

• Provider number

• Provider telephone number

• Provider address

• Provider contact person

• Description of the requested services

• Procedure code (HCPCS, CPT-4 or local Medi-Cal code)

• Rental or purchase

• Modifier or manufacturer code, if appropriate

• Quantity

• Frequency and duration, if appropriate

Use of a discharge planning SAR is not mandatory. If the information is not available at the time of discharge, providers may subsequently request a SAR for individual services.

Service Code Grouping (SCG) A Service Code Grouping (SCG) is a group of reimbursable codes Overview authorized to a provider under one SAR for the care of a CCS client.

An SCG allows providers to render multiple services for a CCS client without the submission of a separate SAR for each service needed by the client. An SCG removes barriers to providing services for CCS clients and is intended to facilitate health care delivery to the CCS client. An SCG is authorized to the physician or podiatrist for a specified length of time, usually up to the time of the CCS client’s next eligibility re-determination. A complete listing of reimbursable HCPCS and CPT-4 codes included in the physician, orthopedic surgeon, ophthalmology, and podiatry SCGs, (and for all other SCGs) is included in the California Children’s Services (CCS) Program Service Code Groupings section in this manual.

cal child sar 4


Orthopedic Surgeon SCG Orthopedic surgeons have a unique SCG (SCG 07) to facilitate the diagnosis and treatment of CCS clients. The orthopedic SCG includes all codes available in the physician SCG (SCG 01). In addition, it

contains codes for diagnostic studies relative to CCS-eligible orthopedic conditions. Ophthalmology SCG Ophthalmologists have a unique SCG (SCG 10) to facilitate

authorization of multiple ophthalmologic procedures. This SCG does not include codes in other SCGs so the ophthalmologist will also use the physician SCG (SCG 01). Refer to the California Children’s Services (CCS) Program Service Code Groupings section in this manual for a list of HCPCS and CPT-4 codes included in the ophthalmology SCG.

Podiatry SCG Podiatrists have a unique SCG (SCG 12) to facilitate authorization of

multiple services. This SCG does not include codes in other SCGs, but does include all the array of codes a podiatrist would need. Individual codes cannot be authorized to podiatrists.

Physician SAR Requirements Physicians may be authorized to provide services for an eligible CCS

client in a Special Care Center (SCC) as well as in a community setting. Physicians may be authorized to provide services by receiving approval for an SCG under one SAR, or separately for specific procedure codes. Refer to the California Children’s Services (CCS) Program Service Code Groupings section in this manual for a list of HCPCS and CPT-4 codes included in the physician SCG.

Services not included in the physician’s SCG must be requested with specific procedure codes on a separate SAR form.

cal child sar 5


Services Not Included The following surgical procedures must be requested on a separate in Physician SCG SAR:

• Surgery: CCS-approved physicians must submit a separate SAR for all surgical procedures with specific requested procedure codes anticipated for the surgical procedure.

A physician surgical assistant and anesthesiologist may be reimbursed using the surgeon’s authorization number. If the presence of a physician surgical assistant is medically necessary and the procedure code is not reimbursable for a physician surgical assistant, a separate SAR must be submitted for surgical assisting.

• Hospital Stay: The CCS-approved hospital must submit a separate SAR for a specific number of inpatient days required for a surgical procedure and post-operative care.

• Outpatient Surgery: CCS-approved physicians must submit a separate SAR for surgery with specific procedure codes anticipated for the surgical procedure. Authorizations for elective surgery may be requested for a specified time period during which the surgery can take place. An outpatient surgery facility must request authorization for a specific period of time during which the physician requests authorization.

• Transplant: A separate SAR must be submitted for transplant services for CCS clients. A SAR for evaluations of transplant suitability and transplant services are directed to the appropriate CCS county or state regional office. Refer to the California Children’s Services (CCS) Program County Office Directory section in this manual for the appropriate county or state office.

cal child sar 6


Inpatient SAR Requirements There are two components to inpatient authorizations, as follows:

Hospital

A hospital authorization is required for the anticipated length of stay for a CCS client. If a CCS client requires additional time in the hospital, the hospital must request an inpatient hospital authorization extension. Physician

This authorization is for CCS-approved physicians with primary responsibility for care of a hospitalized CCS client. This authorization may be provided to physician consultants and physician coverage as requested by an authorized physician. Two authorizations, as described above, are necessary for inpatient care. However, it is not necessary to submit two separate SARs.

Diagnostic Laboratory Laboratory tests related to a CCS-eligible medical condition requested SAR Requirements by an authorized physician are covered if listed in a physician’s SCG.

Laboratory tests not covered in the physician’s authorized SCG require a separate SAR. The physician must provide the laboratory with a SAR number. The laboratory must use the physician’s SAR number when billing for services related to the CCS-eligible medical condition. Providers who use a physician’s SAR number must bill as the rendering provider with the physician’s provider number indicated as the referring provider.

cal child sar 7

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) June 2011

Pharmacy SAR Requirements A pharmacy is not required to submit a separate SAR for reimbursement if a physician’s SCG includes the appropriate drugs to

treat the CCS-eligible medical condition or to treat the Genetically Handicapped Persons Program (GHPP)-eligible client. Physicians prescribing drugs to a CCS or GHPP client must include a SAR

number on the prescription. The rendering pharmacy must bill using the physician’s SAR number.

Drugs and Nutritional The following drugs and nutritional products are not included in a Products Requiring physician SCG and require a separate SAR: Separate Authorization

AbobotulinumtoxinA AHF, Human/VWF, Human Anti-inhibitors Antithrombin III Botulinum Toxin Type A Botulinum Toxin Type B Controlled Substances listed

as Schedule II (GHPP only) Controlled Substances listed

as Schedule III (GHPP only)

Dietary Supplements Factor VIIa (Recombinant)

Factor VIII (Human)

Factor VIII (Recombinant) Factor IX (Heat Treated)

Factor IX (Non-recombinant)

Factor IX (Recombinant) Food Oils Immune Serum Globulin (I.V.)

Immune Serum Globulin Caprylate (I.V.)

Immune Serum Globulin Maltose (I.V.) Infant Formulas

IncobotulinumtoxinA Intrathecal Baclofen Leuprolide Acetate Minerals/Protein

Replacements/Supplements Nutritional Therapy for

Phenylketonuria (PKU) Nutritional Therapy,

Special Formulations Palivizumab Sapropterin Dihydrochloride Sildenafil Somatrem Somatropin Supprelin LA Implant Tadalafil Vardenafil Von Willebrand Factors

cal child sar 8

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) March 2009

Physical, Occupational and Therapy SARs will be accepted only from CCS-approved therapists. Speech Therapy SAR The requested therapy must be for treatment of the client’s Requirements CCS-eligible medical condition. Therapy SARs must include:

• Specific codes for requested therapy services

• The number of requested therapy visits

• A time period for requested therapy

• A copy of the CCS-approved physician prescription for therapy services

• Documentation from the CCS-approved physician that demonstrates medical necessity for therapy

• A current therapy report, if applicable

CCS-approved physical and occupational therapists have a unique SCG, Medical Therapy SCG 11, to facilitate authorization of their consultative services and their services in lieu of the Medical Therapy Unit.

cal child sar 9

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) September 2009

DME and Medical Supply Providers may bill for specific HCPCS Level II product codes for SAR Requirements medical supplies or DME without a product-specific SAR, if: (1) the medical supplies requested do not exceed the billing limits set by

Medi-Cal, and/or the DME requested does not exceed the thresholds for authorization as referenced in Durable Medical Equipment: An Overview in the Allied Health for Durable Medical Equipment and

Medical Supplies Part 2 provider manual; (2) the medical supply codes are not miscellaneous codes; and (3) Medi-Cal does not require a Treatment Authorization Request (TAR) for the medical supply codes.

The provider prescribing the medical supplies or DME must have an

SCG SAR with dates of service that include the dates of service on which the medical supplies and/or DME are dispensed. For Medi-Cal billing limitations and authorization requirements, refer to the Durable Medical Equipment (DME): An Overview section and to the medical supply sections in the appropriate Part 2 Medi-Cal manual.

Note: Medi-Cal age restrictions for incontinence medical supplies do

not apply to such supplies dispensed and billed pursuant to a CCS SAR.

A separate SAR is required for medical supplies if the billing limits of the product(s) (for example, quantity) are exceeded, in accordance with Medi-Cal policy, or there is no specific code for the medical supply (that is, a miscellaneous code is needed for billing), or Medi-Cal requires a TAR for the medical supply. A separate, product-specific SAR also is required for DME that exceeds the thresholds for authorization referenced in Durable Medical Equipment: An Overview.

cal child sar 10


DME In addition to what is required by Medi-Cal, the following must be submitted with a DME SAR for DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment: An Overview.

• Signed prescription by a CCS-approved physician

• HCPCS code

• Detailed description of the DME item

• If using an unlisted or miscellaneous code, an explanation of why an unlisted or miscellaneous code is being used, instead of a HCPCS code

• Model number

• Manufacturer

• Rental or purchase with the appropriate modifier

• Duration of rental

• Any special features Medical Supply In addition to what is required by Medi-Cal, the following must be

submitted with a medical supply SAR for medical supplies that exceed the billing limits set by Medi-Cal policy:


• HCPCS code(s) DME Modifiers A SAR submitted to the CCS program by a DME or hearing aid

provider for DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment: An Overview must contain appropriate modifiers and HCPCS codes. The following modifiers must be included on the SAR, if applicable: NU (new equipment purchase), RP (repair) or RR (rental), as appropriate.

cal child sar 11


Home Health Agencies A SAR must be submitted for Home Health Agencies (HHA) services. SAR Requirements In addition, HHA services can be requested in the following way:

• The authorized physician treating the CCS client as an inpatient may proactively request authorization for anticipated post-discharge HHA services at the same time as the inpatient request.

• The physician may request HHA services using a discharge planning SAR. The CCS program may authorize an initial home assessment and up to three additional visits if requested by a discharging physician at the time of the CCS client’s discharge from the inpatient stay. For additional medically necessary HHA visits, a SAR and the unsigned plan of treatment must be submitted for authorization.

HHA services not requested on a Discharge Planning SAR, nor requested prior to hospitalization, must be submitted within three working days of the date the services began. Any services provided during this three-day grace period must be included on the SAR. CCS authorization is contingent on a client’s CCS program eligibility and the services must be medically necessary.

California Children’s Services (CCS) Program cal child sar Service Authorization Request (SAR) 1


This section includes instructions for submitting a Service Authorization Request (SAR) to the California Children’s Services (CCS) program. SAR Overview The CCS program requires authorization for health care services related to a client’s CCS-eligible medical condition. Providers must

submit a SAR to a CCS county or state regional office, except in an emergency. Only active Medi-Cal providers may receive authorization to provide CCS program services. Services may be authorized for varying lengths of time during the CCS client’s eligibility period.

Providers may request services for CCS clients using one of the following SAR forms located at the end of this section:

• New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488)



The forms are also available at both the Medi-Cal Web site at www.medi-cal.ca.gov and the CCS Web site at www.dhcs.ca.gov/services/ccs/pages/default.aspx. The CCS program case manages and authorizes services for children with CCS-eligible medical conditions who are enrolled in the CCS program, Healthy Families (HF) Program or Medi-Cal program. Only services related to a CCS-eligible medical condition may be authorized and reimbursed by the CCS program.

Physician SAR for A SAR number authorized to a physician may be used for Rendering Provider reimbursement by other health care providers from whom the

physician has requested services, such as laboratory, pharmacy or radiology providers. The rendering provider will use a physician’s SAR number and bill with the authorized physician’s provider number indicated as a referring provider.

Note: This does not apply to SARs issued to CCS Special Care

Centers (SCCs). For more information about SCCs, refer to the California Children’s Services (CCS) Program Special Care Centers section in this manual.

Effective for Dates of Service On or Before March 31, 2009 Only

cal child sar 2


Where to Submit SARs Providers should refer to the California Children’s Services (CCS) Program County Office Directory section in this manual for the appropriate county or state office to submit SARs. If a child resides in an independent county, submit a SAR to the CCS county office. If a child resides in a dependent county, submit a SAR to the appropriate CCS state regional office based on the child’s county of residence.

Providers may fax, mail or hand deliver SARs to the appropriate CCS county or state regional office. After CCS review, providers will receive a hard copy authorization approval or denial for each submitted SAR.

Types of SAR Forms New Referral The New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488) is used when referring an applicant suspected of having a CCS-eligible medical condition to the CCS

program. The applicant’s case may be opened by CCS for diagnostic, treatment or Medical Therapy Program (MTP) services. For more information, refer to the California Children’s Services (CCS) Program Referrals section in this manual.

Established Client The Established CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4509) is used when requesting service authorization for an established CCS client currently enrolled in the

CCS program. The Established Client SAR form does not require as much information about the client as the New Referral SAR form. Providers are to request specific services related to the treatment of the CCS-eligible medical condition when submitting this SAR form.

Discharge Planning The CCS/GHPP Discharge Planning Service Authorization Request (SAR) (form DHCS 4489) is used when requesting specific services for a CCS client who is discharged from an inpatient hospital stay.

The requested services may include, but are not limited to, Home Health Agencies (HHA), Durable Medical Equipment (DME), medical supplies, community services and other medically necessary services related to the CCS-eligible medical condition.


cal child sar 3


The following is the minimum information required for submitting a Discharge Planning SAR:

• Provider name

• Provider number

• Provider telephone number

• Provider address

• Provider contact person

• Description of the requested services

• Procedure code (HCPCS, CPT-4 or local Medi-Cal code)

• Rental or purchase

• Modifier or manufacturer code, if appropriate

• Quantity

• Frequency and duration, if appropriate

Use of a discharge planning SAR is not mandatory. If the information is not available at the time of discharge, providers may subsequently request a SAR for individual services.

Service Code Grouping (SCG) A Service Code Grouping (SCG) is a group of reimbursable codes Overview authorized to a provider under one SAR for the care of a CCS client.

An SCG allows providers to render multiple services for a CCS client without the submission of a separate SAR for each service needed by the client. An SCG removes barriers to providing services for CCS clients and is intended to facilitate health care delivery to the CCS client. An SCG is authorized to the physician or podiatrist for a specified length of time, usually up to the time of the CCS client’s next eligibility re-determination. A complete listing of reimbursable HCPCS and CPT-4 codes included in the physician, orthopedic surgeon, ophthalmology, and podiatry SCGs, (and for all other SCGs) is included in the California Children’s Services (CCS) Program Service Code Groupings section in this manual.


cal child sar 4


Orthopedic Surgeon SCG Orthopedic surgeons have a unique SCG (SCG 07) to facilitate the diagnosis and treatment of CCS clients. The orthopedic SCG includes all codes available in the physician SCG (SCG 01). In addition, it

contains codes for diagnostic studies relative to CCS-eligible orthopedic conditions. Ophthalmology SCG Ophthalmologists have a unique SCG (SCG 10) to facilitate

authorization of multiple ophthalmologic procedures. This SCG does not include codes in other SCGs so the ophthalmologist will also use the physician SCG (SCG 01). Refer to the California Children’s Services (CCS) Program Service Code Groupings section in this manual for a list of HCPCS and CPT-4 codes included in the ophthalmology SCG.

Podiatry SCG Podiatrists have a unique SCG (SCG 12) to facilitate authorization of


Physician SAR Requirements Physicians may be authorized to provide services for an eligible CCS

client in a Special Care Center (SCC) as well as in a community setting. Physicians may be authorized to provide services by receiving approval for an SCG under one SAR, or separately for specific procedure codes. Refer to the California Children’s Services (CCS) Program Service Code Groupings section in this manual for a list of HCPCS and CPT-4 codes included in the physician SCG.

Services not included in the physician’s SCG must be requested with specific procedure codes on a separate SAR form.


cal child sar 5


Services Not Included The following surgical procedures must be requested on a separate in Physician SCG SAR:

• Surgery: CCS-approved physicians must submit a separate SAR for all surgical procedures with specific requested procedure codes anticipated for the surgical procedure.

A physician surgical assistant and anesthesiologist may be reimbursed using the surgeon’s authorization number. If the presence of a physician surgical assistant is medically necessary and the procedure code is not reimbursable for a physician surgical assistant, a separate SAR must be submitted for surgical assisting.

• Hospital Stay: The CCS-approved hospital must submit a separate SAR for a specific number of inpatient days required for a surgical procedure and post-operative care.

• Outpatient Surgery: CCS-approved physicians must submit a separate SAR for surgery with specific procedure codes anticipated for the surgical procedure. Authorizations for elective surgery may be requested for a specified time period during which the surgery can take place. An outpatient surgery facility must request authorization for a specific period of time during which the physician requests authorization.

• Transplant: A separate SAR must be submitted for transplant services for CCS clients. A SAR for evaluations of transplant suitability and transplant services are directed to the appropriate CCS county or state regional office. Refer to the California Children’s Services (CCS) Program County Office Directory section in this manual for the appropriate county or state office.


cal child sar 6


Inpatient SAR Requirements There are two components to inpatient authorizations, as follows:

Hospital

A hospital authorization is required for the anticipated length of stay for a CCS client. If a CCS client requires additional time in the hospital, the hospital must request an inpatient hospital authorization extension. Physician

This authorization is for CCS-approved physicians with primary responsibility for care of a hospitalized CCS client. This authorization may be provided to physician consultants and physician coverage as requested by an authorized physician. Two authorizations, as described above, are necessary for inpatient care. However, it is not necessary to submit two separate SARs.

Diagnostic Laboratory Laboratory tests related to a CCS-eligible medical condition requested SAR Requirements by an authorized physician are covered if listed in a physician’s SCG.

Laboratory tests not covered in the physician’s authorized SCG require a separate SAR. The physician must provide the laboratory with a SAR number. The laboratory must use the physician’s SAR number when billing for services related to the CCS-eligible medical condition. Providers who use a physician’s SAR number must bill as the rendering provider with the physician’s provider number indicated as the referring provider.


cal child sar 7

2 – California Children’s Services (CCS) Program Service Authorization Request (SAR) November 2008

Pharmacy SAR Requirements A pharmacy is not required to submit a separate SAR for reimbursement if a physician’s SCG includes the appropriate drugs to treat the CCS-eligible medical condition. Physicians prescribing drugs to a CCS client must include a SAR number on the prescription. The rendering pharmacy must bill using the physician’s SAR number.

Drugs Requiring Separate The following drugs are not included in a physician SCG and require Authorization a separate SAR:

AHF, Human/VWF, Human Anti-inhibitors Antithrombin III Botulinum Toxin Type A Botulinum Toxin Type B Dietary Supplements Factor VIIa (Recombinant)

Factor VIII (Human)

Factor VIII (Recombinant)

Factor IX (Heat Treated) Factor IX (Non-recombinant)

Factor IX (Recombinant) Food Oils Immune Serum Globulin (I.V.) Immune Serum Globulin Caprylate (I.V.)

Immune Serum Globulin Maltose (I.V.)

Infant Formulas

Intrathecal Baclofen Leuprolide Acetate Minerals/Protein

Replacements/Supplements Nutritional Therapy for

Phenylketonuria (PKU) Nutritional Therapy,

Special Formulations Palivizumab Sapropterin Dihydrochloride Sildenafil Somatrem Somatropin Supprelin LA Implant Tadalafil Vardenafil Von Willebrand Factors


cal child sar 8


Physical, Occupational and Therapy SARs will be accepted only from CCS-approved therapists Speech Therapy SAR The requested therapy must be for treatment of the client’s Requirements CCS-eligible medical condition. Therapy SARs must include:

• Specific codes for requested therapy services

• The number of requested therapy visits

• A time period for requested therapy

• A copy of the CCS-approved physician prescription for therapy services

• Documentation from the CCS-approved physician that demonstrates medical necessity for therapy

• A current therapy report, if applicable

CCS-approved physical and occupational therapists have a unique SCG, Medical Therapy SCG 11, to facilitate authorization of their consultative services and their services in lieu of the Medical Therapy Unit.

DME and Medical Supply Providers may bill for specific product codes for medical supplies SAR Requirements (HCPCS Level III codes 9900A – 9999Z with the exception of

9999A and 9999B), or DME without a product-specific SAR, if the medical supplies requested do not exceed the billing limits set by Medi-Cal, and/or the DME requested does not exceed the thresholds for authorization as referenced in Durable Medical Equipment: An Overview in the Allied Health for Durable Medical Equipment and Medical Supplies Part 2 provider manual. The provider prescribing the medical supplies or DME must have a SCG SAR with dates of service that include the dates of service on which the medical supplies and/or DME are dispensed. For Medi-Cal billing limitations and authorization requirements, refer to the Durable Medical Equipment (DME): An Overview section and to the medical supply sections in the appropriate Part 2 Medi-Cal manual.

Note: Medi-Cal age restrictions for incontinence medical supplies do

not apply to such supplies dispensed and billed pursuant to a CCS SAR.

A separate SAR is required for medical supplies if the billing limits of the product(s) (for example, quantity) are exceeded, in accordance with Medi-Cal policy, or there is no specific code for the medical supply (that is, a miscellaneous code is needed for billing). A separate, product-specific SAR is required for DME that exceeds the thresholds for authorization referenced in Durable Medical Equipment: An Overview.


cal child sar 9


DME In addition to what is required by Medi-Cal, the following must be submitted with a DME SAR for DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment: An Overview.


• HCPCS code



• Model number

• Manufacturer



• Any special features Medical Supply In addition to what is required by Medi-Cal, the following must be

submitted with a medical supply SAR for medical supplies that exceed the billing limits set by Medi-Cal policy:


• HCPCS code(s) DME Modifiers A SAR submitted to the CCS program by a DME or hearing aid

provider for DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment: An Overview must contain appropriate modifiers and HCPCS codes. The following modifiers must be included on the SAR, if applicable: NU (new equipment purchase), RP (repair) or RR (rental), as appropriate.


cal child sar 10



• The authorized physician treating the CCS client as an inpatient may proactively request authorization for anticipated post-discharge HHA services at the same time as the inpatient request.

• The physician may request HHA services using a discharge planning SAR. The CCS program may authorize an initial home assessment and up to three additional visits if requested by a discharging physician at the time of the CCS client’s discharge from the inpatient stay. For additional medically

necessary HHA visits, a SAR and the unsigned plan of treatment must be submitted for authorization.

HHA services not requested on a Discharge Planning SAR, nor requested prior to hospitalization, must be submitted within three working days of the date the services began. Any services provided during this three-day grace period must be included on the SAR. CCS authorization is contingent on a client’s CCS program eligibility and the services must be medically necessary.


California Children’s Services (CCS) Program cal child ser Service Code Groupings 1

2 – California Children’s Services (CCS) Program Service Code Groupings August 2011

This section identifies California Children’s Services (CCS) Service Code Groupings (SCGs). An SCG is a group of procedure codes authorized to a CCS-approved provider for the provision of a group of related health care services that are authorized through the Service Authorization Request (SAR) process. An SCG SAR enables the provider to render care to a CCS client without obtaining repeated procedure-specific SARs. The following effective dates are listed throughout the section:

d September 1, 2010 i December 1, 2010 m April 1, 2011 q August 1, 2011 e September 15, 2010 j January 1, 2011 n May 1, 2011 r September 1, 2011 f October 1, 2010 k February 1, 2011 o June 1, 2011 g November 1, 2010 l March 1, 2011 p July 1, 2011

INCLUDE SERVICE CODE GROUPS 01 THROUGH 12 Physician Service The following is a list of codes that comprise SCG 01 for physicians. Code Group 01 Authorized HCPCS Codes in Physician SCG 01

HCPCS Codes A4217 A4648 A4650 A9500–A9505 A9507–A9510 A9512 A9516–A9517 A9521 A9524 A9526–A9532 A9536–A9548 A9550–A9554 A9556–A9564 A9566–A9567 A9569–A9572 A9576–A9580 A9581–A9583 d A9600 A9604 d A9605 d A9698–A9699 C2634–C2635 C2637–C2641 C2698–C2699 C8929–C8930 C9245–C9247 d C9249 d C9252 d C9254 d C9255 r

C9256 l C9259 r C9264 r C9272 j C9274–C9276 r C9277 l C9279 r C9280 o C9729 p G0430 o G0431 d G0432–G0433 r G0434 o G0435 r G3001 J0129 J0132–J0133 J0135 J0150 k J0152 k J0180 J0210 p J0220 l J0278 p J0285 j J0287–J0289 j J0290 n J0300 p J0330 p J0348 J0360 p J0400

J0460 d J0461 d J0480 J0558 r J0559–J0560 r J0561 r J0570 r J0580 r J0595 q J0597 r J0598 d J0636 J0638 r J0640 J0670 q J0690 l J0696 t J0702 J0718 d J0735 n J0775 l J0795 J0833–J0834 d J0878 J0881–J0882 J0885–J0886 J0894 J0895 n J0960 r J1020 J1030 J1040 J1051 i

J1055 g J1070 J1080 J1100 g J1162 J1170 g J1250 n J1260 J1265 J1267 J1270 J1290 r J1300 J1440–J1441 J1451 J1453 J1455 J1458 J1460 o J1560 o J1571 J1573 J1610 k J1626 d J1630–J1631 n J1640 J1642 p J1644 p J1680 d J1740 J1743 J1745 J1750

J1756 j J1785 m J1786 m J1826 r J1930–J1931 J1945 J1953 J2001 p J2175 f J2248 J2270–J2271 J2275 J2278 J2300 n J2315 J2323 J2325 J2357 J2358 r J2405 J2425 J2426 r J2469 J2501 J2503–J2505 J2562 d J2675 n J2724 J2778 J2785 J2792 J2793 d J2794

cal child ser 2


Authorized HCPCS Codes in Physician SCG 01 (continued)

J2796 d J2805 J2850 J2920 J2930 J3070 n J3095 r J3120 d J3240 J3243 J3262 r J3285 J3300 J3301 j J3303 j J3357 m J3370 J3385 l J3396 J3487–J3488 J3490 J3590 J7309 r J7310–J7311 J7312 l J7321 J7325 J7335 r J7605–J7606 J7611 J7613 J7639 J8705 J9000 g J9001 J9025 J9027 J9033 J9035 J9041 J9045 J9055 J9062 r J9070 n J9150 g J9160 J9171 d J9175 J9185 j

J9201 J9206–J9207 J9208 p J9260–J9261 J9263–J9264 J9266 J9280 m J9302 r J9303 J9305 J9307 r J9310 J9315 r J9320 n J9328 d J9330 J9350 r J9351 r J9355 J9370 n J9390 J9395 k P9010–P9012 P9016–P9017 P9019–P9023 P9031–P9041 P9043–P9048 P9050–P9060 Q0111–Q0113 Q0138–Q0139 d Q0166 Q2043 p Q3014 Q9951 Q9953–Q9967 Q9968 d S0077 S0145 S0148 r S0164 S0189 S0265 S3713 d S3860 S3862 T1014 X4522 X5500 X5509

X5514 m X5516 m X5518 m X5520 m X5522 k X5528 X5530 X5534 m X5536 m X5540 p X5550 n X5552 j X5556 X5558 p X5560 p X5562 p X5564 X5566 p X5572 j X5576 n X5578 n X5580 n X5582 n X5584 n X5586 n X5588 n X5598 m X5600 X5602 l X5604 l X5606 l X5608 l X5610 l X5612 l X5614 l X5620 m X5622 X5626 d X5628 X5630 m X5632 X5634 d X5636 p X5640 m X5642 X5644 X5646 X5648 p X5650

X5652 X5654 m X5656 p X5658 m X5660 X5662 X5666 m X5668 m X5672 X5674 X5676 X5678 m X5680 m X5682 m X5708 X5710 m X5712 m X5714 m X5716 m X5718 m X5720 X5722 X5724 X5726 X5728 X5738 X5740 X5744 X5750 m X5752 X5756 X5762 m X5774 X5776 X5778 m X5780 m X5782 m X5784 m X5786 X5790 X5792 X5794 X5796 q X5798 q X5800 m X5802 m X5804 X5808 X5810 m

X5818 q X5820 q X5822 q X5824 q X5826 m X5828 m X5840 m X5842 m X5844 m X5846 m X5848 m X5854 X5856 X5866 m X5868 m X5872 m X5880 j X5882 m X5888 m X5890 m X5892 m X5894 m X5896 m X5898 m X5904 m X5906 m X5908 m X5910 m X5912 m X5914 m X5918 X5920 X5922 X5924 X5926 X5928 X5930 X5932 m X5934 m X5942 m X5944 m X5960 m X5962 m X5964 m X5966 m X5970 X5972

cal child ser 3

2 – California Children’s Services (CCS) Program Service Code Groupings July 2011


X5980 X5984 m X5988 X5992 m X6002 g X6004 g X6006 g X6008 g X6012 n X6014 X6018 X6020 f X6022 f X6024 f X6026 f X6030 X6042 X6046 i X6048 i X6051 g X6058 X6060 m X6062 X6064 X6070 X6080 X6082 X6084

X6086 g X6090 g X6092 g X6106 m X6108 n X6110 X6114 m X6116 m X6118 m X6122 m X6126 X6136 X6138 m X6140 m X6146 m X6158 m X6160 m X6162 m X6164 X6166 X6168 m X6174 X6178 X6196 m X6198 m X6204 m X6206 X6208

X6214 m X6216 X6220 X6222 X6226 m X6228 X6236 X6240 X6242 X6252 k X6254 k X6258 X6262 X6264 X6274 n X6282 p X6284 p X6286 p X6288 p X6296 p X6298 p X6302 p X6304 p X6306 p X6308 p X6320 X6326 X6328 m

X6330 m X6332 X6334 X6336 X6352 m X6354 X6366 X6408 X6410 m X6422 X6424 X6426 X6432 k X6434 m X6436 m X6438 m X6440 X6442 m X6444 p X6452 m X6454 m X6456 m X6458 m X6460 m X6462 p X6464 p X6466 p X6470 p

X6474 p X6476 p X6478 p X6480 p X6482 p X6486 p X6488 p X6490 p X6492 p X6494 p X6496 p X6504 X6506 X6512 X6514 X6516 X6520 X6522 X6524 X6526 X6528 X6530 X6532 m X6534 m X6550 m X6552 m

cal child ser 4



X6556 m X6558 m X6560 X6562 m X6566 X6578 m X6582 m X6588 m X6598 m X6600 m X6604 X6606 X6610 X6612 n X6614 X6616 X6618 m X6620 X6622 X6624 X6626 X6628 m X6630 X6632 X6634 X6636 m X6638 X6640 m X6642 m X6644 m X6646 m X6648 m X6656 X6658 m X6660 m X6664 m X6666 X6670 m X6672 m X6700 X6702 X6704 X6706

X6714 X6716 X6718 X6720 n X6728 m X6730 m X6732 m X6734 m X6736 m X6738 m X6740 m X6742 X6754 X6758 X6760 m X6764 m X6776 m X6778 m X6780 m X6782 m X6784 m X6792 X6794 X6810 n X6816 X6826 m X6828 p X6830 p X6832 m X6856 m X6862 m X6864 m X6870 m X6888 X6890 X6892 X6894 X6896 m X6912 m X6920 X6942 X6944 m X6968

X6970 m X6972 m X6974 m X6976 k X6978 m X6980 m X6984 m X6996 m X7010 X7025–X7027 X7052 X7060–X7061 X7104 d X7122 X7364 X7366 X7434 X7436 X7444 X7470 m X7488 n X7490 X7492 j X7496 X7498 X7500 g X7502 g X7504 X7506 X7508 X7510 X7512 X7514 g X7520 X7522 n X7524 n X7526 n X7528 X7530 X7532 X7536 m X7540 m X7542

X7544 X7546 X7548 X7550 X7551 m X7552 X7564 X7566 m X7568 m X7570 n X7572 n X7574 n X7576 X7578 X7584 p X7586 X7624 X7632 X7638 X7642 X7644 j X7646 X7648 X7654 k X7700 X7702 X7706 X7708 X7710 X7716 X7718 X7720 X7724 X7726 X9922 X9924 X9926 X9928 X9930 X9932 X9934 X9936 X9938

X9940 X9942 X9944 X9946 X9948 X9950 X9952 X9954 X9956 X9958 X9960 X9962 X9964 X9966 X9968 X9970 Z0100 Z0102 Z0104 Z0106 Z0108 Z0306 Z0316 Z0324 Z0326 Z0328–Z0329 Z7500 Z7502 Z7504 Z7506 Z7508 Z7510 Z7512 Z7514 Z7600 Z7602 Z7610 Z7612

cal child ser 5

2 – California Children’s Services (CCS) Program Service Code Groupings October 2010

Authorized CPT-4 Codes in Physician SCG 01

CPT-4 Codes 00100 00102–00104 00120 00124 00126 00140 00142 00144–00145 00147–00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00211 00212 00214–00216 00218 00220 00222 00300 00320 00322 00326 00350 00352 00400 00402 00404

00406 00410 00450 00452 00454 00470 00472 00474 00500 00520 00522 00524 00528 00529 00530 00532 00534 00537 00539–00542 00546 00548 00550 00560 00561 00562–00563 00566 00567 00580 00600 00604 00620 00622 00625–00626 00630 00632 00634–00635

00640 00670 00700 00702 00730 00740 00750 00752 00754 00756 00770 00790 00792 00794 00796–00797 00800 00802 00810 00820 00830 00832 00834 00836 00840 00842 00844 00846 00848 00851 00860 00862 00864–00866 00868 00870 00872–00873 00880

00882 00902 00904 00906 00908 00910 00912 00914 00916 00918 00920–00922 00924 00926 00928 00930 00932 00934 00936 00938 00940 00942 00944 00948 00950 00952 01112 01120 01130 01140 01150 01160 01170 01173 01180 01190 01200

01202 01210 01212 01214–01215 01220 01230 01232 01234 01250 01260 01270 01272 01274 01320 01340 01360 01380 01382 01390 01392 01400 01402 01404 01420 01430 01432 01440 01442 01444 01462 01464 01470 01472 01474 01480

cal child ser 6

2 – California Children’s Services (CCS) Program Service Code Groupings June 2011

Authorized CPT-4 Codes in Physician SCG 01 (continued)

01482 01484 01486 01490 01500 01502 01520 01522 01610 01620 01622 01630 01632 d 01634 01636 01638 01650 01652 01654 01656 01670 01680 01682 01710 01712 01714 01716 01730 01732 01740 01742 01744 01756 01758 01760 01770 01772 01780 01782 01810 01820 01829–01830 01832 01840 01842 01844 01850 01852

01860 01916 01920 01922 01924–01926 01930–01933 01935–01936 01951–01953 01958 01960–01963 01965–01966 01967–01969 01990–01992 01996 01999 10021–10022 10040 10060–10061 10120 10121 10140 10160 10180 11000–11001 11004–11006 11008 11040–11041 r 11042–11044 11045–11047 r 11055–11057 11100–11101 11200–11201 11400–11404 11406 11420–11424 11426 11440–11444 11446 11600–11604 11606 11620–11624 11626 11640–11644 11646 11720–11721 11730 11732 11740

11750 11752 11760 11762 11765 12001–12002 12004–12007 12011 12013–12018 12020–12021 12031–12032 12034–12037 12041–12042 12044–12047 12051–12057 13100–13102 13120–13122 13131–13133 13150–13153 13160 14000–14001 14020–14021 14040–14041 14060–14061 14300 d 14301–14302 d 14350 15851 16000 16020 17000 17003–17004 17106–17107 17110–17111 17250 21011–21012 d 26010–26011 29049 29055 29058 29065 29075 29085 29105 29125–29126 29130–29131 29200 29220 d

29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580 29581 d 29590 29700 29705 29710 29715 29720 29730 29740 29750 30000 30020 30200 30300 30901 30903 30905–30906 31000 31002 31231 31500 31502 31603 31605 31620 31622–31625

31626–31627 d 31628–31633 31634 r 31635–31638 31640–31641 31643 31645–31646 31656 32421–32422 32550–32551 32552 d 32560 32561–32562 d 36000 36400 36405–36406 36410 36420 36425 36500 36510 36555–36558 36560–36561 36563 36565–36566 36568–36571 36575–36576 36578 36580–36585 36589–36590 36593 36595–36597 36598 36600 36620 36625 36640 36660 36680 38220–38221 38300 38500 38505 40800 40804 40808

cal child ser 7



40819–40820 40830–40831 41000 41005 41800 42000 43234–43237 43239 43753–43757 r 43760–43761 46600 49080 49440–49442 49446 49450–49452 49460 49465 51100–51102 51600 51605 51610 51700 51701–51703 51705 51710 51725–51726 51727–51729 d 51736 51741 51772 d 51784–51785 51792 51795 d 51797–51798 53600–53601 53620–53621 53660–53661 53855 d 53860 r 54000 54050 54055 54056 54057 54060 54065

54500 56442 57400 57410 57415 61000–61001 61070 62267 62270 62272 62284 62290–62291 62310–62311 62318–62319 64450 64455 64632 65205 65210 65220 65222 65430 65435 65800 65805 67500 67515 67700 67710 67715 67800 67801 67805 67810 67820 67840 67850 67930 67935 67938 68020 68040 68100 68110 68200 68801

68810 68840 69000 69020 69100 69105 69200 69210 69420 70010 70015 70030 70100 70110 70120 70130 70134 70140 70150 70160 70170 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70360 70370 70373 70380 70390 70450 70460 70470 70480–70482 70486–70488 70490–70492 70540

70542–70549 70551–70553 70557–70559 71010 71015 71020–71023 71030 71034–71035 71040 71060 71090 71100–71101 71110–71111 71120 71130 71250 71260 71270 71275 71550–71552 71555 72010 72020 72040 72050 72052 72069–72070 72072 72074 72080 72090 72100 72110 72114 72120 72125–72133 72141–72142 72146–72149 72156–72158 72159 72170 72190 72192–72197 72198 72200 72202

72220 72240 72255 72265 72270 72275 72285 72291–72292 72295 73000 73010 73020 73030 73040 73050 73060 73070 73080 73085 73090 73092 73100 73110 73115 73120 73130 73140 73200–73202 73218–73223 73225 73500 73510 73520 73525 73530 73540 73542 73550 73560 73562 73564–73565 73580 73590 73592 73600 73610

cal child ser 8



73615 73620 73630 73650 73660 73700–73702 73718–73723 73725 74000 74010 74020 74022 74150 74160 74170 74176–74178 r 74181–74183 74185 74190 74210 74220 74230 74235 74240–74241 74245–74247 74249–74251 74260 74270 74280 74283 74290–74291 74300–74301 74305 74320 74327–74330 74340 74355 74360 74363 74400 74410 74415 74420 74425 74430 74440

74445 74450 74455 74470 74475 74480 74485 74710 74740 74775 75600 75605 75625 75630 75650 75658 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716 75722 75724 75726 75731 75733 75736 75741 75743 75746 75756 75774 75790 d 75791 d 75801 75803 75805 75807 75809–75810 75820 75822

75825 75827 75831 75833 75840 75842 75860 75870 75872 75880 75885 75887 75889 75891 75893 75984 75989 75992–75996 r 76000–76001 76010 76080 76098 76100–76102 76120 76125 76140 76150 r 76350 r 76380 76496–76499 76506 76510 76511–76513 76514 76516 76519 76529 76536 76604 76645 76700 76705 76770 76775 76776 76800–76802

76805 76810–76812 76815–76817 76820–76821 76825–76828 76830–76831 76856–76857 76870 76872–76873 76880 r 76881–76882 r 76885–76886 76930 76932 76937 76940 76941–76942 76946 76950 76965 76970 76975 76998 76999 77001–77003 77011–77014 77021–77022 77031–77032 77051–77059 77071–77077 77080–77081 78000–78001 78003 78006–78007 78010–78011 78015–78016 78018 78020 78070 78075 78099 78102–78104 78110–78111 78120–78122 78130 78135

78140 78185 78190–78191 78195 78199 78201–78202 78205–78206 78215–78216 78220 78223 78230–78232 78258 78261–78262 78264 78270–78272 78278 78282 78290–78291 78299–78300 78305–78306 78315 78320 78399 78414 78428 78445 78453–78454 d 78456–78458 78460–78461 d 78466 78468 78472 78600–78601 78605–78606 78609–78610 78630 78635 78645 78650 78660 78699–78701 78707–78709 78725 78730 78740 78761

cal child ser 9



78799–78802 78804 78805–78806 78808 78990 78999 79005 79101 79200 79300 79403 79440 79445 79900 79999 80047 80048 80051 80053 80055 80061 80069 80074 80076 80100–80101 o 80102 80150 80152 80154 80156–80158 80160 80162 80164 80166 80168 80170 80172–80174 80176 80178 80182

80184–80186 80188 80190 80192 80194 80195 80196–80198 80200–80202 80299 81000–81003 81005 81007 81015 81025 81050 81099 82000 82003 82009–82010 82013 82016–82017 82024 82030 82040 82042–82044 82045 82055 82085 82088 82101 82103–82106 82107 82108 82120 82127–82128 82131 82135–82136 82139–82140 82143 82145 82150

82154 82157 82160 82163–82164 82172 82175 82180 82205 82232 82239–82240 82247–82248 82252 82261 82270 82271–82272 82274 82286 82300 82306 82307 d 82308 82310 82330–82331 82340 82355 82360 82365 82370 82373–82376 82378–82380 82382–82384 82387 82390 82397 82415 82435–82436 82438 82441 82465 82480 82482

82485–82489 82491–82492 82495 82507 82520 82523 82525 82528 82530 82533 82540–82544 82550 82552–82554 82565 82570 82575 82585 82595 82600 82607–82608 82610 82615 82626–82627 82633–82634 82638 82646 82649 82651–82652 82654 82656 82657–82658 82664 82666 82668 82670–82672 82677 82679 82690 82693 82696 82705

82710 82715 82725–82726 82728 82731 82735 82742 82746–82747 82759–82760 82775–82776 82784–82785 82787–82788 82800 82803 82805 82810 82820 82926 r 82928 r 82930 r 82938 82941 82943 82945–82948 82950–82953 82955 82960 82962–82963 82965 82975 82977–82980 82985 83001–83003 83008 83009

cal child ser 10



83010 83012–83015 83018 83020–83021 83026 83030 83033 83036 83045 83050–83051 83055 83060 83065 83068–83071 83080 83088 83090 83150 83491 83497–83500 83505 83516 83518–83520 83525 83527–83528 83540 83550 83570 83582 83586 83593 83605 83615 83625 83630 83631 83632–83634 83655 83661–83664 83670 83690

83695 83698 83700–83701 83704 83718–83719 83721 83727 83735 83775 83785 83788–83789 83805 83825 83835 83840 83857–83858 83861 r 83864 83866 83872–83874 83876 83880 83883 83885 83887 83890–83894 83896–83898 83900 83901–83906 83907–83909 83912 83913 83914 83915–83916 83918–83919 83921 83925 83930 83935 83945 83951 s

83970 83986 83987 d 83992 83993 84022 84030 84035 84060 84066 84075 84078 84080–84081 84085 84087 84100 84105–84106 84110 84119–84120 84126–84127 84132–84135 84138 84140 84143–84144 84146 84150 84152–84157 84160 84163 84165–84166 84181–84182 84202–84203 84206–84207 84210 84220 84228 84233–84235 84238 84244 84252 84255

84260 84270 84275 84285 84295 84300 84302 84305 84307 84311 84315 84375–84379 84392 84402–84403 84425 84430 84432 84436–84437 84439 84442–84443 84445–84446 84450 84460 84466 84478–84482 84484–84485 84488 84490 84510 84512 84520 84525 84540 84545 84550 84560 84577–84578 84580 84583 84585 84588

84590–84591 84597 84600 84620 84630 84681 84702–84703 84704 84830 84999 85002 85004 85007–85009 85013–85014 85018 85025 85027 85032 85041 85044–85046 85048–85049 85055 85060 85097 85130 85170 85175 85210 85220 85230 85240 85244–85247 85250 85260 85270 85280 85290–85293 85300–85303 85305–85307

cal child ser 11



85335 85337 85345 85347–85348 85360 85362 85366 85370 85378–85380 85384–85385 85390 85396 85397 85400 85410 85415 85420–85421 85441 85445 85460–85461 85475 85520 85525 85530 85536 85540 85547 85549 85555 85557 85576 85597 85598 r 85610–85613 85635 85651–85652 85660 85670 85675 85705 85730

85732 85810 85999–86001 86003 86021–86023 86038–86039 86060 86063 86077–86079 86140–86141 86146–86148 86155–86157 86160–86162 86171 86185 86200 86215 86225–86226 86235 86243 86255–86256 86277 86280 86294 86300–86301 86304 86305 d 86308–86310 86316–86318 86320 86325 86327 86329 86331–86332 86334–86337 86340–86341 86343–86344 86353 86355 –86357 86359–86361 86367

86376 86378 86382 86384 86403 86406 86430–86431 86480 86481 r 86485–86486 86490 86510 86580 86590 86592–86593 86602–86603 86606 86609 86611–86612 86615 86617–86619 86622 86625 86628 86631–86632 86635 86638 86641 86644–86645 86648 86651–86654 86658 86663–86666 86668 86671 86674 86677 86682 86684 86687–86689 86692

86694–86696 86698 86701–86710 86713 86717 86720 86723 86727 86729 86732 86735 86738 86741 86744 86747 86750 86753 86756–86757 86759 86762 86765 86768 86771 86774 86777–86778 86780 d 86781 d 86784 86787 86788–86790 86793 86800 86803–86808 86812–86813 86816–86817 86821–86822 86825–86826 d 86849–86850 86860 86870 86880

86885–86886 86900–86901 86902 r 86903 r 86904–86906 86920–86922 86923 86927 86930–86932 86940–86941 86945 86960 86970–86972 86975–86978 86999 87001 87003 87015 87040 87045–87046 87070–87071 87073 87075–87077 87081 87084 87086 87088 87101–87103 87106–87107 87109–87110 87116 87118 87140 87143 87147

cal child ser 12



87149 87150 d 87152 87153 d 87158 87164 87166 87168–87169 87172 87176–87177 87181 87184–87188 87190 87197 87205–87207 87209 87210 87220 87230 87250 87252–87255 87260 87265 87267 87269–87281 87283 87285 87290 87299–87301 87305 87320 87324 87327–87329 87332 87335–87341 87350 87380 87385 87390–87391 87400 87420 87425 87427 87430 87449–87451 87470-87472 87475–87477 87480–87482

87485–87487 87490–87492 87493 d 87495–87498 87500 87501–87503 r 87510–87512 87515–87517 87520–87522 87525–87542 87550–87552 87555–87557 87560–87562 87580–87582 87590–87592 87620–87622 87640–87641 87650–87653 87660 87797–87804 87807–87810 87850 87880 87899 87900–87904 87905 s 87906 r 87999 88104 88106–88108 88112 88120–88121 r 88130 88140–88143 88147–88148 88150 88152–88155 88160–88162 88164–88167 88172–88175 88177 r 88182 88184–88185 88187–88189 88199 88230 88233 88235

88237 88239–88241 88245 88248–88249 88261–88264 88267 88269 88271–88275 88280 88283 88285 88289 88291 88299–88300 88302 88304–88305 88307 88309 88311–88314 88318–88319 88321 88323 88325 88329 88331–88332 88333–88334 88342 88346–88349 88355–88356 88358 88360–88362 88363 r 88367–88368 88371–88372 88380 88381 88387–88388 d 88399 88720 88740–88741 88749 r 89050–89051 89055 89060 89100 r 89105 r 89125 89130 r

89132 r 89135–89136 r 89140–89141 r 89160 89190 89220 89225 r 89230 89235 r 89240 90281 o 90371 90375–90376 90384–90385 90389 90470 e 90471 90585–90586 90632–90633 90636 90645–90649 90650 t 90655–90658 90660 90663 d 90665 z 90669 90670 90675 90680 90681 90690–90693 90696 90698 90700–90708 90710 90712–90713 90714–90715 90716–90721 90723 90725 90727 90732–90734 90740 90743–90744 90746–90748 90801–90802 90804–90819

90821–90824 90826–90829 90853 90862 90899 91000 r 91010 91011–91012 r 91013 r 91020 91022 91030 91034–91035 91037–91038 91040 91052 r 91055 r 91065 91105 r 91110 91122 91123 r 91132–91133 91299 92002 92004 92012 92014–92015 92018–92020 92025 92060 92070 92081–92083 92100 92120 92130 92132–92134 r 92135 r 92136 92140 92225–92226 92227–92228 r 92230 92235

cal child ser 13



92240 92250 92260 92265 92270 92275 92283–92284 92310–92317 92325 92502 92504 92506–92508 92511–92512 92516 92520 92526 92531–92534 92540 d 92541–92547 92550 d 92551–92553 92555–92557 92559–92565 92567–92568 92569 d 92570 d 92571–92572 92575–92577 92579 92582 92585–92588 92590–92591 92594–92595 92610–92617 92620–92621 92625 92626–92627 92630 92633 92700 92950 92953 92960–92961

92970–92971 93000 93005 93010 93012 r 93014 r 93015–93018 93024–93025 93040–93042 93224–93227 93228–93229 s 93230–93233 r 93235–93237 r 93268 93270 93272 93279–93299 s 93303–93304 93306 s 93307–93308 93312 93315 93318 93320–93321 93325 93350 93351–93352 93724 93745 93750 d 93875 93880 93882 93886 93888 93890 93892–93893 93922–93926 93930–93931 93965 93970–93971 93975–93976 93978–93981

93990 94002–94003 94010 94011–94013 d 94014–94016 94060 94150 94200 94240 94250 94260 94350 94360 94375 94400 94450 94620–94621 94640 94642 94644–94645 94664 94667–94668 94680–94681 94690 94720 94725 94750 94760 94770 94772 95806–95807 95812–95813 95816 95819 95822 95824 95827 95829–95834 95851–95852 95857 95860–95861 95863–95864 95865–95866

95867–95870 95872 95875 95900 95903–95904 95905 d 95920 95925–95930 95934 95936–95937 95950–95951 95953 95955–95958 95970–95975 95978–95979 95991 95992 s 96360–96361 s 96365–96375 s 96379 s 96401–96402 96405–96406 96409 96411 96413 96415–96417 96420 96422–96423 96425 96440 96445 r 96446 r 96450 96521–96523 96542 96549 97010 97012 97014 97016 97018 97020 97022

97024 97026 97028 97032–97036 97039 97110 97112–97113 97116 97124 97139–97140 97530 97532–97533 97597–97598 r 97750 97810–97811 97813–97814 99000 99070 99143–99145 99148–99150 99170 99185–99186 d 99195 99201–99205 99211–99215 99217–99223 99231–99236 99238–99239 99241–99245 99251–99255 99281–99285 99291–99292 99341–99345 99347–99350 99354–99357 99358 f 99360 99464–99467 99477

cal child ser 14


Special Care Centers Special Care Centers (SCCs) are identified with unique SCG 02 to Service Code Group 02 facilitate the diagnosis and treatment of CCS clients. The SCC

Service Code Group includes all codes available in preceding physician SCG 01. In addition, SCG 02 contains codes for diagnostic studies relative to SCC-unique services as follows.

Authorized Codes in SCC SCG 02

HCPCS Codes X3920 X3922 X4100 X4102 X4300–X4301 X4500–X4501 X4506 X4508 X4510 X4530 X4536 X4538 X4540 X4700 X4702 X9514 X9516 X9526 X9528 X9530 X9532 X9534 X9536 X9538 X9540 X9542 Z4300–Z4315 Z5406 Z5900 Z5902 Z5904 Z5906 Z5908 Z5910 Z5912 Z5914 Z5916 Z5918 Z5920 Z5922 Z5924

Z5926 Z5934 Z5936 CPT-4 Codes 20600 20605 20610 21800 21820 31505 31510–31513 31515 31520 31525–31531 31535–31536 31540–31541 31545–31546 31560–31561 31570–31571 31575–31579 31600–31601 31610 31612–31615 31715 31717 31720 31725 31730 32400 32405 32420 32553 d 33010–33011 33202–33203 33206–33208 33210–33218 33220 33222–33226 33233–33238 33240–33241

33243–33244 33249 33282 33284 36002 36005 36010–36015 36100 36120 36140 36145 d 36147–36148 d 36160 36200 36215–36218 36245–36248 36260–36262 36299 36440 36450 36455 36460 36470–36471 36475–36476 36478–36479 36481 36511–36516 36800 36810 36815 36818–36821 37250–37251 38790 38792 40812 41006–41009 41015–41018 41105 41108 41110 41805 42100 42400

42405 42550 42600 42650 42660 42700 42720 42725 42800 42802 42804 42955 43200–43202 43204–43205 43215–43217 43219–43220 43226–43228 43231–43232 43240–43251 43255–43256 43258–43264 43267–43269 43271–43272 43273 s 43450 43453 43456 43458 43460 43600 r 44360–44361 44363 44365–44366 44369 44376–44380 44382–44383 44385–44386 44388–44389 44390–44394 44397 44500 45300 45303

45305 45307–45309 45315 45317 45320–45321 45327 45330–45335 45337–45342 45345 45355 45378–45387 45391–45392 46604 46606 46608 46610–46612 46614–46615 46900 46910 46916–46917 46922 46924 46930 s 47000–47001 47500 47505 47510–47511 47525 47530 47550 48100 48102 48400 49400 49402 49411 d 49418 r 49419 49420 r 49421–49424 49435–49436

cal child ser 15


Authorized Codes in SCC SCG 02 (continued)

50200 50382 50384 50385–50386 50387 50389 50390–50396 50398 50551 50553 50555 50557 50561–50562 50570 50572 50574–50576 50580 50684 50686 50688 50690 50951 50953 50955 50957 50961 50970 50972 50974 50976 50980 51715 51720 52000–52001 52005 52007 52010 52310 t 53020 53200 54001

54505 54700 54800 55000 55100 55300 56820–56821 60000 60100 60300 61020 61026 61050 61055 62273 64400 64402 64405 64408 64410 64412–64413 64415–64418 64420–64421 64425 64430 64435 64445–64450 64470 d 64472 d 64475–64476 d 64479–64480 64483–64484 64505 64508 64510 64517 64520 64530 70350 70355 75557 n

75561 n 75565 n 75894 75896 75898 75900–75902 75940 75945–75946 75952–75954 75956–75959 75960–75962 75964 75966 75968 75970 75978 75980 75982 76496–76498 77261–77263 77280 77285 77290 77295 77299–77301 77305 77310 77315 77321 77326–77328 77331–77334 77336 77338 d 77370 77371–77373 77399 77401–77404 77406–77409 77411–77414 77416–77418 77421–77423

77427 77431–77432 77435 77470 77499 77520 77522–77523 77525 77600 77610 77615 77750 77761–77763 77776–77778 77785–77787 77789–77790 77799 78451–78452 d 78459 78464–78465 d 78473 78478 d 78480 d 78481 78483 78494 78496 78499 78580 78584–78588 78591 78593–78594 78596 78599 78608 78811–78816 90772 90935 90937 90945 90947

93451–93464 r 93501 r 93503 93505 93508 r 93510–93511 r 93514 r 93524 r 93526–93529 r 93530–93533 93539–93545 r 93555–93556 r 93561–93562 93563–93568 r 93571–93572 93600 93602–93603 93609–93610 93612–93613 93615–93616 93618–93622 93799 94656–94657 94660 94662 94799 95805 95808 95810–95811 95990 95999 96900 96910 96912–96913 96920–96922 96999 97799

cal child ser 16


Transplant Centers Transplant Centers are identified with unique SCG 03 to facilitate the Service Code Group 03 diagnosis and treatment of CCS clients. The Transplant Center SCG

includes all codes available in preceding physician SCG 01 and Special Care Centers SCG 02. In addition, SCG 03 contains codes for diagnostic studies relative to Transplant Center unique services as follows.

Authorized Codes in Transplant Centers SCG 03

HCPCS Codes X9518 X9520 X9522 X9524

Z5414 Z5416 Z5422 Z5424 Z5438 Z5446

Z5460 Z5499 Z5805–Z5807 Z5833–Z5835

CPT–4 Codes 96118

Communication Disorder Communication Disorder Centers are identified with unique SCG 04, Centers Service as follows, to facilitate the diagnosis and treatment of CCS clients. Code Group 04 Authorized Codes in Communication Disorder Centers SCG 04

HCPCS Codes V5008 V5010 V5014 V5264 V5267 X4300–X4301 X4303–X4304 X4500–X4501 X4504 X4506 X4508 X4510 X4512 X4514 X4516 X4518 X4520 X4522

X4524 X4526 X4528 X4530 X4532 X4536 X4538 X4540 X4542 X4544 X4546 Z0316 Z0324 Z0326 Z0328–Z0329 Z4300 Z4302 Z4307 Z4311 Z4314

Z5406 Z5822 Z5900 Z5902 Z5904 Z5906 Z5908 Z5910 Z5912 Z5914 Z5916 Z5918 Z5920 Z5922 Z5924 Z5926 Z5928 Z5930 Z5932 Z5934

Z5936 Z5940 Z5944 Z5956 Z7500 Z7502 Z7504 Z7506 Z7508 Z7510 Z7512 Z7514 Z7612 CPT–4 Codes 92550 d 92551–92553 92555–92557

92559–92565 92567 92568 92569 d 92570 d 92571–92572 92575–92577 92579 92582 92583 92585–92588 92590–92591 92594–92595 92620–92621 92625 92626–92627 92630 92633

cal child ser 17

2 – California Children’s Services (CCS) Program Service Code Groupings July 2011

Cochlear Implant Cochlear Implant Centers are identified with unique SCG 05, as Centers Service follows, to facilitate the diagnosis and treatment of CCS clients. Code Group 05 Authorized Codes in Cochlear Implant Centers SCG 05

HCPCS Codes L7510 p L8615–L8618 p L8621–L8624 p L8629 p L9900 p V5008 V5010 V5014 V5264 V5267 X4300–X4301 X4303–X4304 X4500–X4501 X4504 X4506 X4508 X4510 X4512 X4514 X4516 X4518 X4520 X4522 X4524

X4526 X4528 X4530 X4532 X4536 X4538 X4540 X4542 X4544 X4546 X9514 X9516 X9518 X9520 X9522 X9524 X9526 X9528 X9530 X9532 X9534 X9536 X9538 X9540 X9542 Z0316

Z4300 Z4302 Z4307 Z4311 Z4314 Z5406 Z5822 Z5900 Z5902 Z5904 Z5906 Z5908 Z5910 Z5912 Z5914 Z5916 Z5918 Z5920 Z5922 Z5924 Z5926 Z5928 Z5930 Z5932 Z5934 Z5936

Z5940 Z5942 Z5944 Z5950 Z5952 Z5954 Z5956 Z5958 Z5964 Z5966 Z5968 Z7500 Z7502 Z7504 Z7506 Z7508 Z7510 Z7512 Z7514 Z7612 CPT–4 Codes 92510 92550 d

92551–92553 92555–92557 92559–92565 92567–92568 92569 d 92570 d 92571–92572 92575–92577 92579 92582–92583 92585–92588 92590–92591 92594–92595 92601–92604 92620–92621 92625–92627 92630 92633 96110–96111 g 96117–96118

High Risk Infant The High Risk Infant Follow-Up (HRIF) are identified with unique Follow-Up Service SCG 06, as follows, to facilitate the diagnosis and treatment of Code Group 06 CCS clients. Authorized Codes in High Risk Infant Follow-Up SCG 06

HCPCS Codes X4300–X4301 X4500–X4501 X4506 X4508 X4510 X4522 X4530 X4536 X4538 X4540 X9514 X9534

X9542 Z0316 Z4300–Z4307 Z4309–Z4311 Z5406 Z5900 Z5902 Z5906 Z5908 Z5912 Z5914 Z5916 Z5918 Z5920

Z5922 Z5924 Z5934 Z5936 Z7500 Z7502 Z7504 Z7506 Z7508 Z7510 Z7512 Z7514 Z7610 Z7612

CPT–4 Codes 92002 92004 92012 92014 92081–92083 92225–92226 92250 92499 92550 d 92551–92553 92555–92557 92567–92568

92569 d 92570 d 92571–92572 92575–92577 92579 92582 92585–92588 96110–96111 99201–99205 99211–99215 99241–99245

cal child ser 18


Orthopedic Surgeon Orthopedic surgeons are identified with unique SCG 07 to facilitate the Service Code Group 07 diagnosis and treatment of CCS clients. The orthopedic surgeon SCG

includes all codes available in preceding physician SCG 01. In addition, SCG 07 contains codes for diagnostic studies relative to CCS-eligible orthopedic services as follows.

Authorized Codes in Orthopedic Surgeon SCG 07

HCPCS Codes Z4300 CPT–4 Codes 11010–11012 20600 20605 20610 20650 20670 20680 20690 20692–20694 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615–23616 23620 23625 23630 23650 23655 23660

23665 23670 23675 23680 23700 23800 23802 23900 23920–23921 23929–23931 23935 24000 24006 24065–24066 24071 d 24073 d 24075–24077 24079 d 24100–24102 24105 24110 24115–24116 24120 24125–24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 d 24152 24153 d 24155 24160 24164

24200–24201 24220 24300–24301 24305 24310 24320 24330–24332 24340–24346 24357–24359 24360–24363 24365–24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515–24516 24530 24535 24538 24545–24546 24560 24565–24566 24575–24577 24579 24582 24586–24587 24600 24605 24615 24620 24635 24640 24650

24655 24665–24666 24670 24675 24685 24800 24802 24900 24920 24925 24930–24931 24935 24940 24999–25001 25020 25023–25025 25028 25031 25035 25040 25065–25066 25071 d 25073 d 25075–25077 25078 d 25085 25100–25101 25105 25107 25110–25112 25115–25116 25118–25120 25125–25126 25130 25135–25136 25145 25150–25151 25170 25210

25215 25230 25240 25246 25248 25250–25251 25259–25260 25263 25265 25270 25272 25274–25275 25280 25290 25295 25300–25301 25310 25312 25315–25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390–25394 25400 25405 25415 25420 25425–25426 25430–25431 25440–25447 25449–25450 25455

cal child ser 19


Authorized Codes in Orthopedic Surgeon SCG 07 (continued)

25490–25492 25500 25505 25515 25520 25525–25526 25530 25535 25545 25560 25565 25574–25575 25600 25605 25606–25609 25622 25624 25628 25630 25635 25645 25650–25652 25660 25670–25671 25675–25676 25680 25685 25690 25695 25800 25805 25810 25820 25825

25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26020 26025 26030 26034–26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26111 d 26113 d 26115–26117 26118 d 26121 26123

26125 26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210 26215 26230 26235–26236 26250 26255 d 26260 26261 d 26262 26320 26340 26350 26352 26356–26358 26370 26372–26373 26390 26392 26410 26412 26415–26416 26418 26420

26426 26428 26432–26434 26437 26440 26442 26445 26449–26450 26455 26460 26471 26474 26476–26480 26483 26485 26489–26490 26492 26494 26496–26500 26502 26508 26510 26516–26518 26520 26525 26530–26531 26535–26536 26540–26542 26545–26546 26548 26550–26551 26553–26556 26560–26562 26565

26567–26568 26580 26587 26590–26591 26593 26596 26600 26605 26607–26608 26615 26641 26645 26650 26665 26670 26675–26676 26685–26686 26700 26705–26706 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755–26756 26765 26770

cal child ser 20



26775–26776 26785 26820 26841–26844 26850 26852 26860–26863 26910 26951–26952 26989–26992 27000–27001 27003 27005–27006 27025 27027 27030 27033 27035–27036 27040–27041 27043 d 27045 d 27047–27050 27052 27054 27057 27059 d 27060 27062 27065–27067 27070–27071 27075–27078 27079 d 27080 27086–27087 27090–27091 27093 27095–27098 27100 27105

27110–27111 27120 27122 27125 27130 27132 27134 27137–27138 27140 27146–27147 27151 27156 27158 27161 27165 27170 27175–27179 27181 27185 27187 27193–27194 27200 27202 27215–27218 27220 27222 27226–27228 27230 27232 27235–27236 27238 27240 27244–27246 27248 27250 27252–27254 27256–27259 27265–27266 27267–27269

27275 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305–27307 27310 27323–27335 27337 d 27339 d 27340 27345 27347 27350 27355–27358 27360 27364 d 27365 27370 27372 27380–27381 27385–27386 27390–27397 27400 27403 27405 27407 27409 27412 27415 27416 27418 27420 27422

27424–27425 27427–27430 27435 27437–27438 27440–27443 27445–27448 27450 27454–27455 27457 27465–27466 27468 27470 27472 27475 27477 27479 27485–27488 27495–27503 27506–27511 27513–27514 27516–27517 27519–27520 27524 27530 27532 27535–27536 27538 27540 27550 27552 27556–27558 27560 27562 27566 27570 27580 27590–27592 27594 27596

27598–27607 27610 27612–27615 27616 d 27618–27620 27625–27626 27630 27632 d 27634 d 27635 27637–27638 27640–27641 27645–27648 27650 27652 27654 27656 27658–27659 27664–27665 27675–27676 27680–27681 27685–27687 27690–27692 27695–27696 27698 27700 27702–27705 27707 27709 27712 27715 27720 27722 27724–27725 27726 27727

cal child ser 21



27730 27732 27734 27740 27742 27745 27750 27752 27756 27758–27760 27762 27766 27767–27769 27780–27781 27784 27786 27788 27792 27808 27810 27814 27816 27818 27822–27832 27840 27842 27846 27848 27860 27870–27871 27880–27882 27884 27886 27888–27889 27892–27894 27899

28001–28003 28005 28008 28010–28011 28020 28022 28024 28035 28039 d 28041 d 28043 28045–28046 28047 d 28050 28052 28054 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102–28104 28106–28108 28110–28114 28116 28118–28120 28122 28124 28126 28130

28140 28150 28153 28160 28171 28173 28175 28190 28192–28193 28200 28202 28208 28210 28220 28222 28225–28226 28230 28232 28234 28238 28240 28250 28260–28262 28264 28270 28272 28280 28285–28286 28288–28290 28292–28294 28296–28300 28302 28304–28310 28312–28313 28315 28320

28322 28340–28341 28344–28345 28360 28400 28405–28406 28415 28420 28430 28435–28436 28445 28446 28450 28455–28456 28465 28470 28475–28476 28485 28490 28495–28496 28505 28510 28515 28525 28530–28531 28540 28545–28546 28555 28570 28575–28576 28585 28600 28605–28606 28615 28630 28635–28636

28645 28660 28665–28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28899 29000 29010 29015 29020 29025 29035 29040 29044 29046 29086 29799 29904–29907 88361

cal child ser 22


RHC/FQHC Service Rural Health Clinic (RHC) and Federally Qualified Health Center Code Group 08 (FQHC) all-inclusive per visit codes comprise a unique SCG 08, as

follows, to facilitate the diagnosis and treatment of CCS clients. Authorized Codes in RHC/FQHC SCG 08

Per Visit Codes 01 02 03 04

Chronic Dialysis Clinic Chronic Dialysis Clinics are identified with unique SCG 09 to facilitate Service Code Group 09 the diagnosis and treatment of CCS clients. Authorized Codes in Chronic Dialysis Clinic SCG 09

HCPCS Codes J0882 J0886 J1270 J1756 j J2501 Q0139 d X7122 Z6000

Z6002 Z6004 Z6006 Z6008 Z6010 Z6012 Z6014 Z6016 Z6018 Z6020

Z6022 Z6024 Z6026 Z6028 Z6030 Z6032 Z6034 Z6036 Z6038 Z6040

Z6042 CPT–4 Codes 90935 90937 90945 90947

90951–90970 90989 90993 96360–96361 96365–96375 96379 99070

cal child ser 23


Ophthalmology Ophthalmologists are identified with unique SCG 10 to facilitate Service Code Group 10 the diagnosis and treatment of CCS clients. Authorized Codes in Ophthalmology SCG 10

HCPCS Codes Q3014 T1014 CPT-4 Codes 11900 15820–15823 21256 21260–21261 21263 21267–21268 21280 21282 21390 30930 61330 61332–61334 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65235 65260 65265 65270 65272–65273 65275 65280 65285–65286 65290 65400 65410

65420 65426 65436 65450 65600 65710 65730 65750 65755 65756–65757 65770 65778–65779 r 65780–65782 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625

66630 66635 66680 66682 66700 66710–66711 66720 66740 66761–66762 66770 66820–66821 66825 66830 66840 66850 66852 66920 66930 66940 66982–66986 66990 66999 67005 67010 67015 67025 67027–67028 67030–67031 67036 67039–67040 67041–67043 67105 67107–67108 67110 67112 67113 67115 67120–67121 67141 67145 67208 67210 67218 67220–67221 67225

67227–67228 67229 67250 67255 67299 67311–67312 67314 67316 67318 67320 67331–67332 67334–67335 67340 67343 67345 67346 67350 67399–67400 67405 67412–67415 67420 67430 67440 67445 67450 67505 67550 67560 67570 67599 67808 67825 67830 67835 67875 67880 67882 67900–67904 67906 67908–67909 67911–67912 67914–67917 67921–67924 67950 67961

67966 67971 67973–67975 67999 68115 68130 68135 68320 68325–68326 68328 68330 68335 68340 68360 68362 68371 68400 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760–68761 68770 68811 68815 68816 68850 68899 69990 92025 92499

cal child ser 24


Medical Therapy Physical and occupational therapists are identified with unique Service Code Group 11 SCG 11 to facilitate the diagnosis and treatment of CCS clients. Authorized Codes in Medical Therapy SCG 11

HCPCS Codes X3900 X3902 X3904 X3906

X3908 X3910 X3912 X3914 X3916 X3918

X3920 X3922 X3926 X3928 X3930 X3936

X4100 X4102 X4104 X4106 X4110 X4112

X4118 X4120 Z0324 Z0326 Z0328–Z0329

Podiatry Service Podiatrists are identified with unique SCG 12 to facilitate the diagnosis Code Group 12 and treatment of CCS clients.

Authorized Codes in Podiatry SCG 12 HCPCS Codes A4217 C9250 d C9279 r C9363 d J0278 p J0285 j J0287–J0289 j J0290 n J0460–J0461 d J0558 r J0559-J0560 r J0561 r J0570 r J0580 r J0595 q J0670 q J0690 l J0696 J1100 g J1170 g J1610 k J1642 p J1644 p J2001 p J2175 f J2300 n J3301 j J3303 j J3370 L2861 d P9010–P9012 P9016–P9017 P9019–P9023

P9031–P9041 P9043–P9048 P9050–P9060 Q4100–Q4114 r Q4117–Q4121 r S0077 X3900 X3902 X3904 X5514 m X5516 m X5518 m X5520 m X5528 X5530 X5550 n X5558 p X5560 p X5562 p X5572 j X5576 n X5578 n X5580 n X5582 n X5584 n X5586 n X5588 n X5602 l X5604 l X5606 l X5608 l X5610 l X5612 l X5614 l X5676

X5710 m X5712 m X5714 m X5716 m X5718 m X5720 X5722 X5724 X5726 X5738 X5740 X5774 X5796 X5798 X5804 X5818 X5820 X5822 X5824 X5854 X5856 X5866 m X5868 m X5888 m X5890 m X5892 m X5898 m X5906 m X5908 m X5910 m X5922 X5924 X5926 X5928 X5942 m

X5944 m X5980 X5984 m X5988 X6002 g X6004 g X6008 g X6020 f X6022 f X6024 f X6026 f X6042 X6058 X6064 X6086 g X6090 g X6092 g X6116 m X6118 m X6122 m X6136 X6146 m X6158 m X6160 m X6162 m X6166 X6206 X6228 X6240 X6242 X6252 k X6254 k X6282 p X6284 p X6286 p

X6288 p X6296 p X6298 p X6302 p X6304 p X6306 p X6308 p X6332 X6334 X6336 X6408 X6422 X6424 X6426 X6444 X6462 X6464 X6470 X6494 X6496 X6512 X6514 X6516 X6558 m X6588 m X6604 X6606 X6610 X6612 n X6614 X6616 X6620 X6622

cal child ser 25


Authorized Codes in Podiatry SCG 12 (continued) X6624 X6628 m X6646 m X6648 m X6656 X6658 m X6660 m X6664 m X6700 X6702 X6704 X6706 X6714 X6716 X6742 X6754 X6776 m X6870 m X6888 X6890 X6892 X6894 X6970 m X6972 m X6974 m X7010 X7025–X7027 X7700 X7702 X9922 X9924 X9926 X9928 X9930 X9936 X9938 X9940 X9946 X9948 X9950 Z0324 Z0326

Z0328–Z0329 Z7500 Z7502 Z7504 Z7506 Z7508 Z7510 Z7512 Z7514 Z7610 Z7612 CPT-4 Codes 10060–10061 10120–10121 10140 10160 10180 11000 11010–11012 11040–11041 r 11042–11044 11045–11047 r 11055–11057 11100–11101 11200 11420–11424 11426 11620–11624 11626 11720–11721 11730 11732 11740 11750 11752 11755 11760 11762 11765

11900–11901 11960 11981–11983 12001–12002 12004–12005 12041–12042 12044–12045 13131–13133 13160 14040 15050 15100 15115–15116 15851 16000 16020 16035 17000 17003–17004 17106–17108 17110–17111 17270–17274 17276 17999 20000 r 20005 20103 20200 20205 20500–20501 20520 20525 20550–20553 20600 20605 20650 20670 20680 20838 27605–27607 27610 27612–27615

27616 d 27618–27620 27625–27626 27630 27632 d 27634 d 27647–27648 27650 27652 27654 27658–27659 27664–27665 27675–27676 27680–27681 27685–27687 27690–27692 27695–27696 27698 27700 27702–27704 27760 27762 27766 27767–27769 27786 27788 27792 27808 27810 27814 27816 27818 27822–27829 27840 27842 27846 27848 27860 27870 27899 28001–28003 28005

28008 28010–28011 28020 28022 28024 28035 28039 d 28041 d 28043 28045–28046 28047 d 28050 28052 28054–28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28104 28108 28110–28114 28116 28118–28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175

cal child ser 26


Authorized Codes in Podiatry SCG 12 (continued) 28190 28192–28193 28200 28202 28208 28210 28220 28222 28225–28226 28230 28232 28234 28238 28240 28250 28260–28262 28264 28270 28272 28280 28285–28286 28288–28290 28292–28294 28296–28300 28302 28304 28306–28310 28312–28313 28315 28320 28322 28340–28341 28344–28345 28360 28400 28405–28406 28415 28430 28435–28436 28445 28446 28450 28455–28456 28465

28470 28475–28476 28485 28490 28495–28496 28505 28510 28515 28525 28530 28540 28545–28546 28555 28570 28575 28585 28600 28605–28606 28615 28630 28635 28645 28660 28665 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28890 28899 29345 29355

29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29540 29550 29580 29581 d 29700 29705 29730 29740 29750 29799 29891–29894 29904–29907 37799 64450 64455 64632 64702 64704 64726 64782–64783 64831–64832 64834 64837 71010 71020 73500 73590 73600 73610 73615 73620 73630 73650 73660

76000 76140 76499 76881–76882 r 76999 80047 80048 80051 80053 81000–81003 82310 82374 82435 82565 82800 82803 82805 82810 82947–82948 84132 84295 84520 84525 85002 85004 85007 85013–85014 85018 85025 85027 85044–85045 85170 85175 85300–85303 85305–85307 85335 85345 85347 85396 85397 85520 85576 85610–85611 85651–85652

85660 85670 85675 85730 85732 85810 85999 86038–86039 86060 86063 86077–86079 86140–86141 86162 86235 86430–86431 86590 86900–86901 86903 r 86904–86906 86945 87040 87070–87071 87073 87075–87077 87081 87084 87086 87088 87101–87103 87106 87205–87207 87210 87220 87250 87252–87255 87640–87641 87653 87906 r 88104 88106–88108 88112 88300

cal child ser 27


Authorized Codes in Podiatry SCG 12 (continued)

88302 88304–88305 88307 88309 88311–88314 88318–88319 88321 88323 88325 88329 88331–88334 88342

88346–88349 88355–88356 88358 88360–88362 88367–88368 88371–88372 88380 88381 88387–88388 d 88399 89050–89051 90471

90703 93799 93925–93926 95831 95851 97010 97012 97014 97016 97018 97022 97024

97026 97028 97032–97036 97039 97110 97112–97113 97116 97124 97139–97140 97597–97598 r 97810–97811 97813–97814

99000 99070 99201–99203 99211–99213 99218–99223 99231–99232 99241–99243 99251–99253 99281–99284

cal child ser 28


EXCLUDE SERVICE CODE GROUPS Physician Service SCG 51 is authorized by CCS to a physician for the provision of Code Group 51 surgical services to a CCS client. For more information on SCG 51,

see CCS Numbered Letter 02-0510 at www.dhcs.ca.gov/services/ccs/Documents/ccsnl020510.pdf.

Excluded Codes in Physician SCG 51

HCPCS Codes C9270 o J0585-J0587 J1459 o J1559 o J1561–J1562 o J1566 o J1568–J1569 o J1572 o J1599 o J1675 J1950 J7185–J7187 J7189–J7190 J7192–J7195 J7196 r J7197–J7198 J9217 J9226 Q2040 o S2055 S2065 X7034 X7036 X7108

X7452 X7454 X7494 Z0312 Z7304 Z7306 Z7308 Z7312 Z7314 Z7316 Z7320 Z7322 CPT-4 Codes 32851–32854 33250–33251 33261 33935 33945 36822 38204–38215 38230 38240–38242

43644–43645 43770–43774 43842–43843 43845–43848 43886–43888 44135 47135 47140–47142 50320 50340 50360 50365 50380 54400 54406 54408 54410–54411 54415–54417 59000–59001 59012 59015 59020 59025 59030 59050–59051

59070 59072 59074 59076 59100 59120–59121 59130 59135–59136 59140 59150–59151 59160 59300 59320 59325 59350 59400 59409 59414 59510 59514 59525 59610 59612 59618 59620

59812 59820–59821 59830 59840–59841 59850–59852 59855–59857 59870–59871 59897–59899 61885–61886 62360–62362 64553 64568 r 64573 r 69930 90283 o 90378 93623–93624 93631 93640–93642 93650–93652 95115 95180 95199 95873–95874

California Children’s Services (CCS) Program cal child spec Special Care Centers 1

2 – California Children’s Services (CCS) Program Special Care Centers September 2007

This section contains information about California Children’s Services (CCS) Special Care Centers (SCCs). SCC The CCS program has a system of SCCs throughout the state,

providing comprehensive, coordinated health care to children with complex, handicapping medical conditions. SCCs are multidisciplinary, multispecialty teams that evaluate a client’s medical condition and develop a comprehensive, family-centered plan of health care for the client. SCCs facilitate provision of timely, coordinated treatment for the CCS client and are usually located in conjunction with CCS approved tertiary level medical centers. Each SCC is individually reviewed and approved by CCS to ensure that it complies with CCS program standards.

List of SCCs A list of SCCs is available on the “CCS/GHPP Special Care

Center Directory” Web page at the CCS Web site (www.dhcs.ca.gov/services/ccs). Providers may search the Directory according to SCC type, such as cardiac or craniofacial; facility or hospital name; or SCC number.

cif co CIF Completion 1

2 – CIF Completion March 2011

The Claims Inquiry Form (CIF) is used to request an adjustment for either an underpaid or overpaid claim, request a Share of Cost (SOC) reimbursement or request reconsideration of a denied claim. The CIF can also be used as a tracer. Use the Remittance Advice Details (RAD) as described below to reconcile claims pending follow-up:

• Underpayment or overpayment adjustments to a paid claim under RAD heading “Approves” (reconcile to Medi-Cal Financial Summary).

• Reconsideration of a denied claim under RAD heading “Denies” (do not reconcile to Medi-Cal Financial Summary).

• Trace a “lost claim” that does not appear on a RAD. CIF examples of SOC reimbursement and Medicare/Medi-Cal crossover claims are included in the CIF Special Billing Instructions section in the appropriate Part 2 manual. For CIF submission information, refer to the CIF Submission and Timeliness Instructions section in this manual. Exceptions to CIFs may not be used for the following inquiries. Using CIFs All Claims: Do not submit a CIF for a claim that reported an incorrect provider Incorrect Provider Number number; for example, billing under an individual provider number

instead of a group rendering number. Instead, rebill within the six-month billing limit or billing limit exceptions time frame. If this period has expired, submit an appeal.

All Claims Denied for National Providers may not use CIFs in connection with claims denied as a Correct Coding Initiative Edits result of National Correct Coding Initiative (NCCI) edits. Providers

must submit an appeal. Refer to the Correct Coding Initiative: National section in the appropriate Part 2 manual.

Pharmacy Claims: Do not submit a hard copy CIF to reverse a pharmacy claim originally POS Network submitted over the Point of Service (POS) network unless you are

returning an overpayment. Instead, reverse the claim over the POS network, then resubmit a corrected claim if necessary. Refer to the POS Device User Guide for information about reversing claims over the POS network (www.medi-cal.ca.gov, click “References” and then “User Guides.”) You also may call the POS/Internet Help Desk at

1-800-427-1295 or contact your software vendor. Pharmacy Claims: Pharmacy providers should not submit a hard copy CIF to reverse a RTIP claim originally submitted over the Real-Time Internet Pharmacy

(RTIP) claim submission system unless they are returning an overpayment. Instead, they should reverse the claim through the RTIP system, then resubmit a corrected claim if necessary. Providers may call the POS/Internet Help Desk at 1-800-427-1295 for information about reversing claims through the RTIP system.

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2 – CIF Completion March 2011

Inpatient Claims Do not submit a CIF to request reconsideration of a denied inpatient claim if claim lines must be added or deleted. Instead, submit a new original claim within the six-month billing limit or billing limit exceptions time frame. If this period has expired, submit an appeal.

Compound Claims Do not submit a CIF to request reconsideration of a denied pharmacy

compound claim if ingredients must be added or deleted. Instead, submit a new original claim within the six-month billing limit or billing limit exceptions time frame. If this period has expired, submit an appeal.

Certain RAD Messages Do not submit a CIF for the following Remittance Advice Details (RAD)

code messages. Providers should submit an Appeal Form instead. A review by a person in the appeals unit is commonly used to resolve denials if the claim has a unique circumstance needing human intervention. Additional information is available in the Appeal Process Overview and Appeal Form Completion sections of the appropriate provider manual.

Code Message 0002 The recipient is not eligible for benefits under the Medi-Cal

program or other special programs.

0010 This service is a duplicate of a previously paid claim.

0072 This service is included in another procedure code billed on the same date of service.

0095 This service is not payable due to a procedure, or procedure and modifier, previously reimbursed.

0314 Recipient not eligible for the month of service billed.

0326 Another procedure with a primary surgeon modifier has been previously paid for the same recipient on the same date of service.

0525 NCCI (National Correct Coding Initiative) void of a column 2 claim previously paid when a column 1 claim has been processed for the same provider and date of service.

9940 NCCI claim line is billed with multiple NCCI modifiers.

9941 NCCI column 2 procedure code is not allowed when column 1 procedure has been paid.

9942 NCCI quantity billed is greater than the allowed MUE (Medically Unlikely Edit) quantity.

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2 – CIF Completion February 2010

Completion Instructions The following steps are required when completing a CIF for all for All Inquiries inquiry types:

1. Complete Boxes 3, 4 and 5 (Provider Name/Address, Provider Number and Claim Type).

2. Complete the lines on the CIF according to the type of inquiry

(such as, reconsideration of a denied claim, underpayment adjustment or overpayment adjustment).

Note: CIFs for SOC reimbursement, inpatient claims, pharmacy

compound claims, Medicare/Medi-Cal crossover claims and tracers should be submitted separately (refer to “Share of Cost, Inpatient, Compounds, Crossovers and Tracers: Separate CIFs Required” later in this section).

3. Sign and date the bottom of the form and submit the signed,

original copy of the CIF and all attachments to the Department of Healthcare Services (DHCS) Fiscal Intermediary (FI). CIFs submitted without a signature will be returned to the provider.

Denied, Under/Overpaid Denied, underpaid, overpaid and void claim inquiries may be and Void Inquiries combined on one CIF. These types of inquiries each follow unique completion instructions and requirements for attaching documentation. Correcting NDC/UPN To correct the National Drug Code (NDC) and/or Universal Product Information for Number (UPN) information previously submitted on a claim form, Physician-Administered complete Boxes 7, 8, 9 and 13 for each claim line being resubmitted. Drug or Disposable Medical These are required fields. Boxes 10, 11 and 12 are optional fields. Supply Claims The corrected NDC/UPN information (Product ID Qualifier, NDC, Unit

of Measure Qualifier or NDC/UPN Quantity) should be entered in the Remarks field.

Reconsideration To request reconsideration of a denied claim line after the six-month of Denied Claims billing limit, complete Boxes 7, 8, 9 and 13 for each claim line being

resubmitted. These are required fields. Boxes 10, 11 and 12 are optional fields. (Refer to “Delay Reasons” in the claim form submission and timeliness instructions section of the appropriate Part 2 manual.)

Attach a legible copy of the corrected original claim form, a copy of the RAD on which the claim line was denied and all pertinent documentation. In the Remarks field, enter the denial code and clearly state the reason the claim should not have been denied.

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Underpayment/Overpayment A CIF adjustment should be used to correct both under and over Adjustments and Voids payments. However, this transaction type is different than requesting

a full payment recovery, which is a void. A CIF adjustment is a one-step process. If requesting an adjustment for an underpaid or overpaid claim, the adjustment is completed in one transaction, with the adjudication results appearing on a future RAD. The corrected Claim Control Number (CCN) will appear as a credit and a debit, and will be reflected on the same RAD.

A CIF void may be requested to fully recover or recoup monies paid. In many instances, the provider’s goal was to return funds to a Medi-Cal or specialty program. The CIF void accomplishes that in one step. However, there are cases in which the provider wants to void the original payment and submit a corrected claim. The CIF void is largely an automated process and cannot perform two functions. As a result only the void can be processed.

Providers requiring a void and subsequent resubmission of a corrected claim, use a two-step process. First, the CIF void must be submitted to recoup the full payment. Once the void appears on a future RAD, the provider completes the secondary step of submitting an Appeal to request processing of the corrected claim.

The Appeal must be filed within 90 days from the date indicated on the RAD on which the void appeared. The Appeal must include a corrected claim copy, a copy of the RAD that indicated the payment retraction, and any other supporting documentation.

Detailed Appeal submission and documentation requirements are included in the Appeal Form Completion section of the appropriate Part 2 provider manual. Exemptions to the CIF void process are explained in the CIF Special Billing Instructions section of the appropriate Part 2 provider manual.

CIFs for underpaid claims require completion of Boxes 7, 8, 9, 10 and 11 for each claim line for which reconsideration is requested. CIFs for overpaid claims require completion of Boxes 7, 8, 9, 10 and 12. Boxes 13, 14 and 15 are optional fields for both underpaid and overpaid claims.

Note: A CIF requesting reconsideration of an underpaid claim must

be received within six months from the date of the RAD. CIFs received after six months from the date of the RAD on which the underpayment was indicated are subject to automatic denial. CIFs for overpaid claims may be submitted at any time. Refer to the Part 1 manual section CIF Overview.

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Additional CIF guidelines are as follows:

• Attach a legible copy of the corrected original claim form, a copy of the RAD on which the claim line was paid and all pertinent documentation.

• In the Remarks field, clearly state the reason an adjustment is requested.

Note: Although the most recent Claim Control Number (CCN) may be a denied line, the CCN used for an adjustment to an underpaid

or overpaid claim must be from the paid line on the RAD. Share of Cost, Inpatient, Separate CIFs must be submitted for Share of Cost (SOC) Compounds, Crossovers and reimbursement, inpatient claims, pharmacy compound claims, Tracers: Separate CIFs Medicare/Medi-Cal crossover claims and tracers. For additional CIF Required information about SOC and crossover claims, refer to the CIF Special

Billing Instructions section in the appropriate Part 2 manual. Inpatient Claims An inpatient claim with numerous claim lines is processed as one line.

An inquiry may not be made for individual lines on an inpatient claim. Therefore, only one claim line per CIF must be submitted.

Compound Claims A pharmacy compound claim with numerous ingredients is processed

as one line. An inquiry may not be made for individual ingredients on a compound claim. Therefore, only one claim line per CIF must be submitted.

Tracers To request a tracer on a claim, complete Boxes 7, 8, 13, 14 and 15.

Leave Boxes 9, 10, 11 and 12 blank.

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Claim Form Attachments Claim form attachments must be a corrected photocopy of the same type of claim originally submitted. Make all corrections directly on the photocopied claim. If the photocopy of the original claim cannot be corrected, submit an appeal (refer to the Appeal Process Overview section in the Part 1 manual).

CIF Attachments Acceptable CIF attachments are listed in the following chart. The

documentation applies to all inquiries except tracers and requests for SOC reimbursement.

Acceptable CIF Attachments Except for Tracers and SOC Reimbursement

Treatment Authorization Request (TAR) or vision claim indicating prior approval “By Report” documentation Completed Sterilization Consent Form Explanation of Medicare Benefits (EOMB)/Medicare Remittance Notice

(MRN)/Medicare Remittance Advice (RA) Explanation of Benefits (EOB) from Other Health Coverage,

such as CHAMPUS or Kaiser Drugs and supplies itemization list, manufacturer’s invoice or description,

including the name of the medication, dosages, strength and unit price Supplier’s invoice indicating wholesale price and item billed Manufacturer’s name, catalog (model) number and manufacturer’s catalog page

showing suggested retail price Copy of Point of Service (POS) printout or Internet eligibility response attached to

the claim on an 8½ x 11-inch sheet of white paper

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CIF Completion Reminders

ALL

INQ

UIR

IES

AD

JUST

MEN

T

CR

OSS

OVE

R,

INPA

TIEN

T A

ND

PH

AR

MA

CY

CO

MPO

UN

DS

DEN

IAL

SHA

RE

O

F C

OST

TRA

CER

Always enter an “X” in the box to indicate the claim type. X

Enter no more than four claim inquiries per form. Note: This does not apply to crossover and inpatient claims.

X

Fill out each line completely. Do not use ditto marks (“) nor draw an arrow to indicate repetitive information.

X

All information must be exactly the same as that on the Remittance Advice Details (RAD). For example, an incorrect ID number on the RAD should be copied exactly on the CIF.

X

Only one claim line per CIF. X Be sure the recipient ID number and Claim Control

Number on the CIF exactly match the numbers on the RAD.

X

RAD not required. X X Enter the recipient’s original ID (the number issued

prior to being enrolled in a no-SOC program). X X

Do not use the Remarks area for additional inquiries. X State clearly and precisely what is being requested in

the Remarks area. X

Always indicate the denial or adjustment reason code in the Remarks area. X X

Secure documentation to the upper right-hand corner of the CIF. X X X X

Do not attach any documentation. X Only original CIFs are accepted. Photocopies will be

returned. X

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Explanation of Form Items Each numbered item below refers to an area on the CIF.

Item Description 1. Correspondence Reference Number. For the FI use only. 2. Document Number. The pre-imprinted number identifying

the CIF. 3. Provider Name/Address. Enter the following information:

Provider Name, Street Address, City, State and ZIP code. 4. Provider Number. Enter the provider number. 5. Claim Type. Enter an “X” in the box indicating the claim type.

Only one box may be checked. Vision Care Providers: When billing for services prior to July 1, 2006, indicate claim type 07 (Vision). For services billed on or after July 1, 2006, indicate claim type 05 (Physicians/Allied).

6. Delete. Enter an “X” to delete the entire line. When Box 6 is marked “X,” the information on the line will be “ignored” while

the system continues to process the other claim lines. Enter the correct billing information on another line. 7. Patient’s Name or Medical Record Number. Enter up to the

first 10 letters of the patient’s last name or the first 10 characters of the patient’s Medical record number.

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Item Description 8. Patient’s Medi-Cal ID Number. Enter the recipient ID

number that appears on the Remittance Advice Details (RAD) showing adjudication of that claim.

9. Claim Control Number. Enter the 13-digit number assigned

by FI to the claim line in question. (This number is found on the RAD.) If this item is blank, the inquiry line will be considered a tracer request.

10. Attachment. Enter an “X” when attaching documentation and

when resubmitting a denied claim. Note: All claim inquiries should have attachments except

when submitting a tracer. Refer to the CIF Submission and Timeliness Instructions section in this manual.

11. Underpayment. Enter an “X” for an underpayment

adjustment of a paid claim. Do not mark Box 11 if the claim was denied.

12. Overpayment. Enter an “X” if all or part of the claim was

overpaid. Do not mark Box 12 if the claim was denied.

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2 – CIF Completion June 2010

Item Description 13. Date of Service. In six-digit format (MMDDYY), enter the

date the service was rendered. For block-billed claims, enter the “From” date of service.

14. NDC/UPN or Procedure Code. Providers should enter the

appropriate procedure code, modifier, drug or supply code if applicable. Codes of fewer than 11 digits should be left-justified. For outpatient claims, do not enter the revenue code in this field. Long Term Care and Inpatient providers leave blank.

15. Amount Billed. Enter the amount originally billed, using the

two boxes to the right of the decimal point to reflect cents. 16. Remarks. Use this area to state the reason for submitting a

CIF and include the corresponding line number if listing multiple claim lines on the CIF.

17. Signature. The provider or an authorized representative

must sign the CIF.

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Figure 1. Sample Claims Inquiry Form (CIF): Denial Resubmission, Underpayment and Overpayment Returns for All Claim Types Except Inpatient and Crossover Claims.

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Figure 2. Sample Claims Inquiry Form (CIF): Tracer Request.

cif sp op CIF Special Billing Instructions for Outpatient Services 1

2 – CIF Special Billing Instructions for Outpatient Services Outpatient Services 394 July 2007

Claims Inquiry Forms (CIFs) submitted for Share of Cost (SOC) reimbursement and Medicare/Medi-Cal crossover claims for outpatient services require unique completion instructions explained in this section. Examples of completed CIFs for these types of inquiries also are included. Refer to the CIF sections in this manual for additional billing information. SHARE OF COST (SOC) CLAIMS Submitting SOC CIFs In addition to submission requirements in the CIF Completion section

in this manual, use the following instructions to request SOC reimbursement for previously paid claims (see Figure 1 on a following page in this section):

• All services on the CIF must be for SOC reimbursement.

• Share of Cost (SOC) CIFs may contain multiple claim lines, but all lines must be for the same recipient. Use each CIF to submit inquiries for only one recipient.

• Complete Boxes 7, 8, 9, 10 and 13.

Note: The CIF must contain the date of service in Box 13. Providers submitting improperly completed CIFs will receive one of four CIF denial letters, numbers 70 through 73.

• In the Remarks section, state “SOC reimbursement; MC 1054 attached.”

• Attach a Share-of-Cost Medi-Cal Provider Letter (MC 1054).

Note: If requesting SOC reimbursement for denied claims or claims not previously submitted, submit the MC 1054 with the new claim.

• If SOC is reduced to other than zero, wait a minimum of 30 days before submitting a CIF.

Note: The Remittance Advice Details (RAD) will not display a specific message for an SOC reduced to zero. The RAD will display message 433 for an SOC reduced to other than zero.

claims sp op 2

2 – CIF Special Billing Instructions for Outpatient Services Outpatient Services 400 January 2008

Figure 1. Sample Claims Inquiry Form (CIF): SOC Reimbursement for a Previously Paid Claim.

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MEDICARE/MEDI-CAL CROSSOVER CLAIMS Submitting Crossover CIFs In addition to submission requirements in the CIF Completion section

in this manual, use the following instructions to complete a CIF for Medicare/Medi-Cal crossover claims. A CIF may be used to request reconsideration of a denied crossover claim (see Figure 2 on a following page in this section), an adjustment of an underpaid or overpaid Medi-Cal claim, or an adjustment related to a Medicare adjustment. Refer also to the CIF Submission and Timeliness Instructions section in this manual for additional requirements.

Note: Charpentier claims must not be submitted on a CIF. Refer to

“Charpentier Rebilling” in the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual for specific instructions.

Reconsideration of Follow the instructions below to complete a CIF for reconsideration of Denied Crossover Claims a denied crossover claim:

• Submit only one crossover claim (that is, only one Claim

Control Number [CCN]) for each CIF.

• Enter in Box 9 the 13-digit CCN of the most recently denied crossover claim from the Remittance Advice Details (RAD). This number must end with a “99” or “00.”

• Mark Attachment in Box 10.

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• Attach the following documentation:

– If Part B services are billed to a Part A intermediary, submit a clear copy of the original crossover claim form billed to Medi-Cal.

– If Part B services are billed to a Part B carrier, submit a clear copy of one of the following:

Original crossover claim form billed to Medi-Cal

Claim form billed to Medicare

Facsimile of the claim form submitted to Medicare (same format as CMS-1500 claim form with visible background)

− All claims for Part B services must include a clear copy of both of the following:

Medicare Remittance Notice (MRN)/Medicare National Standard Intermediary Remittance Advice (Medicare RA)

Medi-Cal RAD showing the Medi-Cal crossover denial

• In the Remarks section, indicate the denial code and include any additional information needed to correct the claim.

Note: It is acceptable to make corrections on the claim copy being submitted with the CIF, if the Remarks section is completed.

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Adjustments to Medi-Cal Follow the instructions below to complete a CIF for an adjustment to a Crossover Payments Medi-Cal crossover payment:

• Submit only one crossover claim (that is, only one Claim Control Number [CCN]) for each CIF.

• Enter in Box 9 the 13-digit CCN of the most recent crossover payment from the Remittance Advice Details (RAD). This number must end with a “99” or “00.”

• Mark Attachment in Box 10.

• Mark Underpayment in Box 11 or Overpayment in Box 12.

• Attach the following documentation for an adjustment not related to a Medicare adjustment:

− If Part B services are billed to a Part B carrier, submit a clear copy of one of the following:


Claim form billed to Medicare

Facsimile of the claim form submitted to Medicare (same format as CMS-1500 with visible background)

− If Part B services are billed to a Part A intermediary, submit a clear copy of the original crossover claim form billed to Medi-Cal.


Medicare MRN/RA

Medi-Cal RAD showing the Medi-Cal crossover payment

• In the Remarks section, indicate the specific reason for the adjustment and the type of action desired.

Note: It is acceptable to make corrections on the claim copy being submitted with the CIF if the Remarks section is completed.

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Adjustments Related When Medicare automatically crosses over a Medicare adjustment, it to Medicare Adjustments does not include the original Medi-Cal Claim Control Number (CCN).

As a result, the Medicare adjustment claim number cannot be matched to the originally submitted Medi-Cal crossover claim. These Medicare adjustments will deny as duplicates of the original crossover claim if they were approved and appear as RAD code 010 on a Remittance Advice Details (RAD). Therefore, to obtain correct reimbursement, providers must submit all Medicare adjustments on a CIF after they receive a RAD denial.

When completing a CIF for an adjustment as a result of a Medicare adjustment, follow these additional instructions:

• Include only one crossover claim (that is, only one Claim

Control Number [CCN]) per CIF.

• Enter in Box 9 the 13-digit CCN of the most recent crossover payment from the Remittance Advice Details (RAD). This number must end with a “99” or “00.”

• Mark Attachment (Box 10).

• Mark Underpayment (Box 11) or Overpayment (Box 12).

• Attach the following documentation for an adjustment related to a Medicare adjustment:

− If Part B services are billed to a Part B carrier, submit a clear copy of the Medicare adjusted claim form and one of the following:


Original claim form billed to Medicare

Facsimile of the original claim form submitted to Medicare (same format as CMS-1500 with visible background)

− If Part B services are billed to a Part A intermediary, submit a clear copy of the original crossover claim form billed to Medi-Cal.


Original and adjusted Medicare MRN/RA

Medi-Cal RAD showing the Medi-Cal crossover payment or denial

• In the Remarks section, indicate the specific reason for the adjustment and the type of action desired. Note: It is acceptable to make corrections on the claim copy

being submitted with the CIF if the Remarks section is completed.

cif sp op 7


Tracing Crossover Claims A CIF must be submitted to trace a crossover claim. Do not submit a crossover claim (CMS-1500/UB-04 and Medicare MRN/RA) to trace crossover claims.

Billing Tips for Following these billing tips will help prevent rejections, delays, Crossover CIFs mispayments, and/or denials of crossover CIFs:

• Only one crossover claim (that is, only one Claim Control

Number [CCN]) can be processed on a single CIF. Additional crossover claims submitted on the same CIF will be rejected.

• Always include supporting documentation with a CIF, or the claim will be denied.

• All supporting documentation must be clear, concise and complete.

• Failure to mark Attachment (Box 10) may cause the claim to be denied.

• Verify that the CCN in Box 9 of the CIF has 13 digits and ends with “00” or “99.”

• If requesting adjustment of a crossover claim, use the approved CCN that is being requested for adjustment.

• If requesting reconsideration of a denied crossover claim, use the CCN that matches the most recently adjudicated claim.

• Failure to mark Underpayment (Box 11) or Overpayment (Box 12), when applicable, may cause a delay in claim processing.

• Do not mark Underpayment (Box 11) or Overpayment (Box 12) if submitting a CIF for reconsideration of a denial.

• Failure to complete the Remarks section of the CIF may cause claim denial or delayed processing.

• To ensure timeliness requirements are met, refer to the CIF Submission and Timeliness Instructions section in this manual.

cif sp op 8

2 – CIF Special Billing Instructions for Outpatient Services Outpatient Services 408 September 2008

Figure 2. Sample Claims Inquiry Form (CIF): Denied Crossover Claim.

cif sub CIF Submission and Timeliness Instructions 1

2 – CIF Submission and Timeliness Instructions February 2010

This section explains guidelines and time frames for submitting a Claims Inquiry Form (CIF). Refer to the CIF sections in this manual for additional billing information. INTRODUCTION Reconsideration of The following timeliness requirements apply to CIFs requesting Denied Claims reconsideration of denied claims. Within Six-Month If a claim is denied and the date of service is within the six-month Billing Limit billing limit or the billing limit exceptions time frame, a corrected

original claim form may be submitted instead of completing a CIF. Refer to the claim form submission and timeliness instructions section in the appropriate Part 2 manual.

Beyond Six-Month Providers must file a CIF requesting reconsideration of a denied claim Billing Limit if the Remittance Advice Details (RAD) on which the claim appears is

received after the six-month billing limit or the billing limit exceptions time frame. The CIF must be received by the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) within six months from the date of the RAD on which the claim appears as denied. CIFs received after six months are subject to automatic denial.

Adjustments Adjustments may be requested for underpaid and overpaid claims. Underpaid/Overpaid A CIF requesting reconsideration of an underpaid claim must be Claims received within six months from the date of the RAD. CIFs received

after six months from the date of the RAD on which the underpayment was indicated are subject to automatic denial. CIFs for overpaid claims may be submitted at any time. For additional information, refer to “Underpayment and Overpayment Adjustments” in the CIF Completion section of this manual.

cif sub 2

2 – CIF Submission and Timeliness Instructions December 2009

Tracers Use the following guidelines when submitting a tracer:

• Do not submit a CIF to trace a claim appearing on a current RAD as “Suspends.” A suspended claim is pending adjudication and will appear on a future RAD as either paid or denied.

• Submit tracer requests separately from CIF adjustment requests and denial resubmissions.

• Do not send any documents with a tracer.

FI ACKNOWLEDGEMENT OF CIF Claims Inquiry Within 15 days of receipt the FI will acknowledge requests for Acknowledgement adjustments and reconsideration of denied claims with a Claims

Inquiry Acknowledgement (see sample Claims Inquiry Acknowledgement on a following page in this section). The claim should appear on a RAD within 45 days after the Claims Inquiry Acknowledgement is received. The Claims Inquiry Acknowledgement serves as proof of timely submission if additional claim follow-up is needed. If the FI does not respond after the initial CIF is filed, providers should file an appeal.

Claims Inquiry A Claims Inquiry Response Letter indicating the status of the claim is Response Letter sent to providers when the CIF/tracer is processed. The letter

includes a 13-digit Correspondence Reference Number (CRN), which contains the Julian date the CIF/tracer was received and can be used to verify that the CIF/tracer was submitted within the six-month billing limit.

If the response letter states the claim cannot be located, resubmit the claim as an appeal. Enclose any necessary attachments, including a copy of the Claims Inquiry Response Letter.

Providers may receive a Claims Inquiry Response Letter requesting additional information. To submit a new CIF, follow the instructions on the response letter.

cif sub 3


ADDITIONAL INQUIRIES Submitting Subsequent If further action is desired after a claim inquiry appears on the CIFs/Appeals RAD as paid or denied, providers may submit either another CIF or an

appeal.

All subsequent CIFs must be submitted within six months from the date of the RAD. An appeal must be submitted within 90 days. Include copies of all previous documentation with any CIFs or appeals submitted to substantiate timely follow-up (such as a Claims Inquiry Acknowledgement, Remittance Advice Details (RAD), Resubmission Turnaround Document (RTD) or Claims Inquiry Response Letter).

CIF SUBMISSION Documenting The FI must receive a CIF or tracer within the same six-month Timely Submission billing limit as the original claim if the CIF or tracer is to be used to prove timely submission when filing an appeal.

Example: A service is provided on October 15, and a claim is completed and submitted on October 31. If the claim does not appear on a RAD by December 15, a CIF/tracer must be received by April 30 (six months from the month of service) to serve as documentation of timely submission. However, if the date of service is within the six-month billing limit or billing limit exceptions time frame, providers may submit a new claim.

Original CIFs Only original CIFs are accepted for processing. Photocopied CIFs will

be returned to providers. Where to Submit CIFs CIFs should be addressed to the FI at the following address:

HP Enterprise Services P.O. Box 15300 Sacramento, CA 95851-1300

cif sub 4

2 – CIF Submission and Timeliness Instructions January 2008

CLAIMS INQUIRY ACKNOWLEDGEMENT

Sample Claims Inquiry Acknowledgement.

cif sub 5


Status Numbers One Claims Inquiry Acknowledgement is sent to providers for each and Messages CIF submitted. The center portion of the acknowledgement reflects all

of the line information entered by a provider on the original CIF. The last column of each line displays a status number that translates into the following messages:

Status Message 01 Accepted for resubmission of denied claim or

underpayment/overpayment. 02 Accepted. Tracer status letter will be generated. 03 Rejected. Only one CCN per crossover CIF allowed. 04 Rejected. Only one CCN per inpatient CIF allowed. 05 Rejected. Crossovers must be on a separate CIF. 06 Rejected. CMPND CIFs must be only CIF and line 01.

Status Inquiries Providers may inquire about the status of a CIF by calling the Telephone Service Center (TSC) at 1-800-541-5555 and referencing the document number or Correspondence Reference Number (CRN) found at the bottom left portion of the Claims Inquiry Acknowledgement. The document number matches the document number at the upper right-hand corner of the CIF. Any written correspondence regarding claim lines referenced on a CIF acknowledgement should include copies of the Claims Inquiry Acknowledgement (or reference to the CRN and document numbers), CIF and all other pertinent documents.

dental Dental Benefits 1

2 –Dental Benefits September 2007

This section describes the procedures and codes used to bill dental benefits for children. Fluoride Varnish HCPCS code D1203 (topical application of fluoride [prophylaxis not included] – child) is a Medi-Cal and managed care benefit for children younger than 6 years of age, up to three times in a 12-month

period.

When the procedure is delegated to them and follows a protocol established by the attending physician, nurses, physicians and other medical personnel are legally permitted to apply fluoride varnish.

forms leg Forms: Legibility and Completion Standards 1

2 – Forms: Legibility and Completion Standards December 2009

This section explains the basic standards required for processing of the following paper billing forms: claims, Treatment Authorization Requests (TARs), Resubmission Turnaround Documents (RTDs), Claims Inquiry Forms (CIFs), and Appeal Forms (90-1). For instructions about completing a specific paper billing form, refer to the appropriate form completion instructions in this manual. Optical Character Recognition (OCR) equipment is used by the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) to scan all submitted paper billing forms. Accuracy, completeness and clarity are important. Forms cannot be processed if applicable information is not supplied or is illegible. To ensure that forms will be scanned and processed efficiently, adhere to the following instructions. Submitting Forms Submit the top copy of the form to the FI and retain the second copy

for your records. The top copy contains the important bar code (if applicable) and clarity necessary for proper scanning.

Since each form is processed separately, it is important not to batch or staple original forms together.

Note: Keep all “Part A” RTDs for your records. Return only “Part B”

for processing. Unacceptable Forms Carbon copies, photocopies, computer-generated form facsimiles or

forms created on laser printers are not acceptable for the forms mentioned in this section.

forms leg 2

2 – Forms: Legibility and Completion Standards November 2009

Pin-Fed Forms Remove all perforated sides and separate each individual form. For accurate scanning, leave a ¼-inch border on the left and right side of the form after removing the perforated sides.

Do Not Fold To expedite the sorting and preparation of claims for scanning, do not or Crease fold or crease forms to fit into small-sized envelopes. Enclose forms

in full-sized, color-coded envelopes supplied at no charge by the FI.

Note: There are no color-coded envelopes for RTDs. Typed and Handwritten Type all information (using capital letters) on forms whenever possible Forms for clarity and accuracy using 10 point font or larger (not to exceed the

size of the field). Do not use script or italic font. Only typed or computer-printed forms can be scanned by OCR equipment.

Handwritten forms should be printed neatly and accurately using black ballpoint pen only. Do not use red pencils or red ink ballpoint pens. All requirements pertaining to typed forms, such as entering data within the text space, apply to handwritten forms.

Printer and Typewriter Use black film-type or high-quality ribbons. Ribbons should be Ribbons changed regularly to ensure that a clear, distinct character is printed.

Blurred or light printing may be misread by OCR equipment. Uneven or dirty typewriter or printer keys also cause misreads. Laser printers are recommended.

Type in Designated Type only in areas of the form designated as fields. Be sure the data Areas Only falls completely within the text space and is properly aligned. Many of

the forms have Elite and Pica alignment boxes and typewriter alignment dots to adjust the font and tabs.

Do not type in undesignated white space, shaded areas or areas labeled “FOR F.I. USE ONLY.” These areas are reserved for use by the Fiscal Intermediary only.

forms leg 3

2 – Forms: Legibility and Completion Standards May 2010

Alpha or Numeric Characters Use only alphabetical letters or numbers in data entry fields. No Highlighting Pens Never highlight information. When the form and attachments are

scanned on arrival by the FI, the highlighted area will show up only as a black mark, obscuring the highlighted information.

Date Format Enter dates in the six-digit format (MMDDYY) without slashes. Refer

to the appropriate billing form instructions for additional date format information.

Provider Signature Medi-Cal requires providers or their designees to sign and date all

claim forms, TARs, RTDs, CIFs or appeals. An original signature is required on all forms. The signature must be written, not printed. Stamps, initials or facsimiles are not acceptable. When signing, use a black ballpoint pen.

Note: Be sure that the signature is within the boundaries of the

designated field. OCR equipment scans markings outside the boundaries of the field as data, resulting in the need for manual review by claim examiners, extending the processing time of the claim.

Corrections Do not strike over errors or use correction tapes or fluids. Deletion Box A line data delete box appears on CIFs, Appeals and on Pharmacy

and Long Term Care claim forms. To correct an error, place an “X” in the Delete field and enter the correct information on the next available line. When the Delete field is checked, the system ignores that line and continues to process the other claim lines.

forms leg 4

2 – Forms: Legibility and Completion Standards December 2009

CMS-1500 and The CMS-1500 and UB-04 claim forms do not contain Delete fields. UB-04 Claim Forms To correct line data information, providers are required to draw a line

through the entire detail line in blue or black ballpoint ink as follows:

• On the CMS-1500, draw the line from the left border of Date(s) of Service (Box 24A) to the right border of Rendering Provider ID Number (Box 24J). Enter the correct information on the next available claim line.

• On the UB-04 claim form, draw the line from the left border of Revenue Code (Box 42) to the right border of the unlabeled field (Box 49). Enter the correct information on the next available claim line.

Attachments Attached documentation for claims, CIFs or appeals should clearly

reference the claim field number or procedure that requires additional documentation. The claim field number on the attachment should be legible, underlined or circled in black ballpoint pen. Allow adequate line space between each claim field number description.

Attachments must be single-sided because only one side of the document is scanned. Carbon copies of documents are not acceptable. Instead, make a photocopy of the original.

Attach undersized documentation to an 8½ x 11-inch sheet of 20-lb. white bond paper with non-glare tape. Cut oversized attachments (such as Explanation of Medicare Benefits [EOMB]/Medicare Remittance Notice [MRN]/Remittance Advice [RA]) in half, and tape each half to a separate 8½ x 11-inch white sheet of paper.

Note: Do not highlight or use tape to fasten attachments to the claim

form. Do not use original claims as attachments since they may be interpreted as original claims.

POS and Internet Point of Service (POS) printouts and Internet eligibility responses, with

Eligibility Verification Confirmation (EVC) numbers, are not required as attachments unless the claim is over one year old.

forms reo Forms Reorder Request: Guidelines 1

2 – Forms Reorder Request: Guidelines December 2009

This section explains how to order forms and envelopes used to bill and seek authorization for Medi-Cal services. Providers who need a Provider Forms Reorder Request for either hard copy or electronic billing should contact the Telephone Service Center (TSC) at 1-800-541-5555. Ordering Hard Copy Use the Department of Health Care Services (DHCS) Fiscal Billing Forms Intermediary (FI) Provider Forms Reorder Request, included with each shipment of forms, to order forms and envelopes (see Figure 1 in the provider-specific Forms: Reorder Request section of this manual for additional information). To meet all billing deadlines, providers should maintain a two- to three-month supply of the FI provider forms at all times. Allow two to three weeks for delivery of new forms. There is no charge for these forms and envelopes.

Note: The FI does not supply Resubmission Turnaround Document (RTD) return envelopes.

Long Term Care and Pharmacy providers: Mail reorder request

forms to: HP Enterprise Services P.O. Box 15400 Sacramento, CA 95851-1400 Inpatient and Outpatient providers: Mail reorder request forms to: HP Enterprise Services P.O. Box 15600 Sacramento, CA 95852-1600 Allied Health, Medical Services and Vision Care providers: Mail

reorder request forms to: HP Enterprise Services P.O. Box 15700 Sacramento, CA 95852-1700

forms reo 2

2 – Forms Reorder Request: Guidelines December 2009

Ordering Electronic Providers can order electronic billing forms by calling the Telephone Billing Forms Service Center (TSC) at 1-800-541-5555. The following forms are

available:

• Attachment Control Form (ACF)

• Medi-Cal Electronic Billing Claim Certification and Control Sheets (80-1) and (80-1C)

Note: To order additional 80-1 and 80-1C forms, use the Forms Reorder Request-Electronic Billing form that is included with each shipment of forms.

Mail requests for electronic billing forms to:


Change of Address/ Before ordering forms, providers must notify DHCS of any address Change of Status or status change. See the Provider Guidelines section in the Part 1

manual for more information. Returned Orders If providers request pre-imprinted claim forms and the address or

status does not match the DHCS Provider Master File, the order will be returned with a Medi-Cal Supplemental Changes (form DHCS 6209). Providers should use this form to update the DHCS Provider Master File and re-order pre-imprinted claim forms. See the Provider Guidelines section in the Part 1 manual for information about this form.

Forms Reorder Request: forms reo io Inpatient and Outpatient Services 1

2 – Forms Reorder Request: Inpatient and Outpatient Services November 2009

This section explains how to complete the Provider Forms Reorder Request. Providers who need a Provider Forms Reorder Request for either hard copy or electronic billing should contact the Telephone Service Center (TSC) at 1-800-541-5555.

Figure 1. Sample Department of Health Care Services (DHCS) Fiscal Intermediary (FI) Provider Forms

Reorder Request for Inpatient and Outpatient.

forms reo io 2

2 – Forms Reorder Request: Inpatient and Outpatient Services November 2009

Explanation of Form Items Item Description

1. INDICATE QUANTITY DESIRED (X): Mark one of the quantity boxes or indicate “other” amount desired.

2. ENVELOPES: Indicate number of envelopes requested. (500

envelopes per box) 3. SHIP-TO ADDRESS: Enter the name and address where the

forms are to be shipped. Include an “Attention” line if applicable. Do not use a P.O. Box.

4. PROVIDER NUMBER: The provider number or billing service

submitter number must be in this box or the Provider Forms Reorder Request form will be returned.

Request for Mental Health To order Request for Mental Health Stay in Hospital (18-3) forms, Stay in Hospital (18-3) enter “18-3 TAR Forms” next to the quantity ordered on the “18-1” line of the FI Provider Forms Reorder Request. Complete the rest of the request as previously described.

genetic Genetically Handicapped Persons Program (GHPP) 1

2 – Genetically Handicapped Persons Program (GHPP) May 2011

This section contains program, policy and billing information for the Genetically Handicapped Persons Program (GHPP). Program Overview GHPP provides health care services for adults with genetic diseases

specified in the California Code of Regulations (CCR), Title 17, Section 2932.

GHPP eligibility determination, case management and authorization of

services are conducted on a statewide basis by the GHPP state office. Eligibility Requirements Applicants must meet age, residence, income and medical eligibility

requirements to participate in GHPP. Applicants must submit a Genetically Handicapped Persons Program (GHPP) Application for Services form, available from the GHPP state office and may be required to apply for Medi-Cal benefits. Eligibility requirements are as follows.

Age Applicants must be 21 years of age or older. Persons younger than 21

years of age with GHPP-covered genetic diseases may be eligible for GHPP if they have been determined to be financially ineligible to receive services from the California Children’s Services (CCS) program.

Residence Applicants must be residents of California. Income There is no income limit for GHPP eligibility. However, some clients

may be required to pay an annual enrollment fee to GHPP. The amount of the fee is determined using a sliding scale based on adjusted gross income and family size.

genetic 2

2 – Genetically Handicapped Persons Program (GHPP) June 2004

Medical GHPP covers genetic disease conditions specified in the California Code of Regulations (CCR), Title 17, Section 2932. The following is a summary of GHPP-eligible medical conditions. This summary is solely to assist providers in understanding the medical eligibility criteria of the GHPP program. It is not an authoritative statement of, and should not be cited as, authority for any decisions, determinations or interpretations of the GHPP program. Providers should refer to the CCR section cited above for a definitive description of GHPP medical eligibility requirements.

• Hemophilia and other genetic bleeding disorders • Cystic fibrosis • Hemoglobinopathies with anemia, including sickle-cell disease

and thalassemia • Huntington’s disease, Joseph’s disease, Friedreich’s ataxia and

other neurologic diseases • Phenylketonuria, Wilson’s disease, galactosemia and other

metabolic diseases • von Hippel-Lindau syndrome

genetic 3


Authorization A Service Authorization Request (SAR) must be submitted to the GHPP state office for approval of all GHPP diagnostic and treatment services. GHPP will issue a unique SAR number for services authorized by GHPP. This SAR number will begin with “99.” The SAR number must be indicated on the claim in the appropriate Treatment Authorization Request (TAR) field prior to submission to the Department of Health Care Services (DHCS) Fiscal Intermediary (FI). The provider is responsible for ensuring their SAR number is indicated on the claim. Claims submitted without the correlating SAR number in the TAR field will be denied.

For emergency services, authorization must be obtained from GHPP by the close of the next business day following the date of service.

Providers may request services for GHPP clients using one of the following SAR forms. Copy-ready versions of these forms are located at the end of the California Children’s Services (CCS) Program Service

Authorization Request (SAR) section in this manual: • New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488)



The forms are also available at both the Medi-Cal website at www.medi-cal.ca.gov and GHPP website at www.dhcs.ca.gov/services/ghpp/Pages/AuthorizationsClaims.aspx.

Only active Medi-Cal providers may receive authorization to provide GHPP program services. Services may be authorized for varying lengths of time during the GHPP client’s eligibility period.

http://www.medi-cal.ca.gov/

genetic 4


Where to Submit SARs Providers may fax, mail or hand deliver SARs to the GHPP state office. After GHPP review, providers will receive a hard copy authorization approval or denial for each submitted SAR.

Genetically Handicapped Persons Program MS 8105 P.O. Box 997413 Sacramento, CA 95899-7413 (916) 327-0470 (800) 639-0597 Fax: (916) 327-1112 or (916) 327-0670

Types of SAR Forms New Referral The New Referral CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4488) is used when referring an applicant Who may have a GHPP-eligible medical condition to the GHPP

program. The applicant’s case may be opened by GHPP for diagnostic or treatment services.

Established Client The Established CCS/GHPP Client Service Authorization Request (SAR) (form DHCS 4509) is used when requesting service authorization for an established GHPP client currently enrolled in the

GHPP program. The Established Client SAR form does not require as much information about the client as the New Referral SAR form.

Discharge Planning The CCS/GHPP Discharge Planning Service Authorization Request (SAR) (form DHCS 4489) is used when requesting specific services for a GHPP client who is discharged from an inpatient hospital stay.

The requested services may include, but are not limited to, Home Health Agencies (HHAs), Durable Medical Equipment (DME) or medical supplies.

Service Code Grouping (SCG) A Service Code Grouping (SCG) is a group of reimbursable codes

authorized to a provider under one SAR for the care of a GHPP client. An SCG allows providers to render multiple services for a GHPP client

without the submission of a separate SAR for each service needed by the client. A SCG removes barriers to providing services for GHPP clients and is intended to facilitate health care delivery to the GHPP client.

An SCG is authorized to the physician, podiatrist or Special Care

Center for a specified length of time, usually up to the end of the GHPP client’s next eligibility redetermination.

genetic 5


A complete listing of reimbursable HCPCS and CPT-4 codes included in the physician, orthopedic, surgeon, ophthalmology and podiatry SCGs, (and for all other SCGs) is included in the California Children’s Services (CCS) Program Service Code Groupings section of the Medi-Cal manual.

Physician SCG Physicians assign a unique SCG (SCG 01) to facilitate the diagnosis

and treatment of GHPP clients. The orthopedic SCG includes all codes available in the physician SCG (SCG 01).

Special Care Center SCG Special Care Centers (SCCs) are identified with unique SCG (SCG 02)

to facilitate the diagnosis and treatment of GHPP clients. The SCC Service Code Group includes all codes available physician SCG 01. In addition, SCG 02 contains codes for diagnostic studies relative to SCC-unique services.

Transplant SCG Transplant Centers are identified with unique SCG (SCG) 03 to

facilitate the diagnosis and treatment of GHPP clients. The Transplant Center SCG includes all codes available in physician SCG 01 and Special Care Centers SCG 02, in addition to transplant related HCPCS codes.

Orthopedic Surgeon SCG Orthopedic surgeons have a unique SCG (SCG 07) to facilitate the

diagnosis and treatment of GHPP clients. The orthopedic SCG includes all codes available in the physician SCG (SCG 01).

RHC/FQHC Service SCG Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) all-inclusive per visit codes comprise a unique SCG 08 to

facilitate the diagnosis and treatment of GHPP clients. Chronic Dialysis Clinic SCG Chronic Dialysis Clinics are identified with unique SCG 09 to facilitate the diagnosis and treatment of GHPP clients. Ophthalmology SCG Ophthalmologists have a unique SCG (SCG 10) to facilitate

authorization of multiple ophthalmologic procedures. This SCG does not include codes in other SCGs so the ophthalmologist will also use the physician SCG (SCG 01).

genetic 6


Medical Therapy SCG Physical and occupational therapists are identified with unique SCG 11 to facilitate the diagnosis and treatment of GHPP clients. Podiatry SCG Podiatrists have a unique SCG (SCG 12) to facilitate authorization of


Physician SAR Requirement Physicians may be authorized to provide services for an eligible GHPP

client in a Special Care Center (SCC) as well as in a community setting. Physicians may be authorized to render services by receiving approval for an SCG under one SAR, or separately for specific procedure codes. Refer to the California Children’s Services (CCS) Program Service Code Groupings section in this manual for a list of CPT-4 and HCPCS codes included in the physician SCG.

Physician SAR for An SCG SAR authorized to a physician may be shared for Rendering Provider reimbursement by other health care providers from whom the

physician has requested services, such as laboratory, pharmacy or radiology providers. The rendering provider will use a physician’s SAR number and indicate the NPI of the authorized physician as a referring or attending provider.

Services not included in the physician SCG must be requested with

specific procedure codes and may be listed on one SAR form. Services Not Included Instructions for services not included in a physician SCG are as In Physican SCG follows: Inpatient surgery: Physicians must submit a SAR for surgical

procedures. All anticipated surgical procedure codes and SCG 01 may be listed on one SAR. A physician surgical assistant and anesthesiologist may be reimbursed using the surgeon’s authorization number. If the presence of a physician surgical assistant is medically necessary and the procedure code is not reimbursable for a physician surgical assistant, a separate SAR must be submitted for surgical assisting. Hospital Stay: The hospital must submit a separate SAR for a specific number of inpatient days required for a surgical procedure and post-operative care.

genetic 7


Outpatient Surgery: Physicians must submit a SAR for surgical procedures. All anticipated surgical procedure codes and SCG 01 may be listed on one SAR. Authorization for elective surgery may be requested for a specified time period during which the surgery can take place. The outpatient surgery facility will be reimbursed using the surgeon’s authorization number. Transplant: A separate SAR must be submitted for transplant services for GHPP clients.

Inpatient SAR Requirements The following two separate authorizations are required for approval of

a client’s inpatient care. Both authorizations may be requested on the same SAR: Hospital: A hospital authorization is required for the anticipated length of stay for the GHPP client. If the client requires additional time in the hospital, the hospital must request an inpatient hospital authorization extension. Physician with Primary Responsibility to Care for Hospitalized Client: This authorization may be granted to physician consultants and other physicians as requested by the authorized physician.

Diagnostic Laboratory Laboratory tests related to a GHPP-eligible medical condition are SAR Requirements covered if listed in a physician’s SCG. SAR Requirements Laboratory tests not covered in the physician’s authorized SCG require

a separate SAR. The physician must provide the laboratory with a SAR number. The laboratory must use the physician’s SAR number when billing for services related to the GHPP-eligible medical condition. Providers who use a physician’s SAR number must bill as the rendering provider with the physician’s provider number indicated

as the referring or attending provider.

genetic 8

2 – Genetically Handicapped Persons Program (GHPP) June 2011

Pharmacy SAR Requirements A pharmacy is not required to submit a separate SAR for reimbursement if the treating physician has authorization to prescribe drugs to the GHPP client. The rendering pharmacy must bill using the physician’s SAR number. Physicians prescribing drugs to a GHPP

client must include the SCG SAR number on the prescription. Drugs and Nutritional The following drugs and nutritional products are not included in a Products Requiring physician SCG and require a separate SAR: Separate Authorization

Abobotulinumtoxin A AHF, Human/VWF, Human Anti-inhibitors Antithrombin III Botulinum Toxin Type A Botulinum Toxin Type B Controlled Substances listed

as Schedule II (GHPP only) Controlled Substances listed

as Schedule III (GHPP only)

Dietary Supplements Factor VIIa (Recombinant)

Factor VIII (Human)

Factor VIII (Recombinant)

Factor IX (Heat Treated)

Factor IX (Non-recombinant)

Factor IX (Recombinant) Food Oils Immune Serum Globulin (I.V.)

Immune Serum Globulin Caprylate (I.V.)

Immune Serum Globulin Maltose (I.V.) Infant Formulas

IncobotulinumtoxinA Intrathecal Baclofen Leuprolide Acetate Minerals/Protein Replacements/Supplements

Nutritional Therapy for Phenylketonuria (PKU)

Nutritional Therapy, Special Formulations

Palivizumab Sapropterin Dihydrochloride Sildenafil Somatrem Somatropin Supprelin LA Implant Tadalafil Vardenafil Von Willebrand Factors

Procedure Codes Claims for GHPP services must include appropriate procedure codes.

With few exceptions, all procedure codes that are reimbursable by Medi-Cal may be used to bill for GHPP services.

genetic 9


DME and Medical Supply Providers may bill for specific HCPCS Level II product codes for SAR Requirements medical supplies or DME without a product-specific SAR when such

items are Medi-Cal benefits, if: (1) the medical supplies requested do not exceed the billing limits set by Medi-Cal, and/or the DME requested does not exceed the thresholds for authorization as referenced in Durable Medical Equipment: An Overview in the Allied Health for Durable Medical Equipment and Medical Supplies Part 2 provider manual; (2) the medical supply codes are not miscellaneous codes; and (3) Medi-Cal does not require a Treatment Authorization Request (TAR) for the medical supply codes.

The provider prescribing the medical supplies or DME must have an

SCG SAR with dates of service that include the dates of service on which the medical supplies and/or DME are dispensed. For Medi-Cal billing limitations and authorization requirements, refer to the Durable Medical Equipment (DME): An Overview section and to the medical supply sections in the appropriate Part 2 Medi-Cal manual.

A separate SAR is required for medical supplies if the billing limits of the product(s) (for example, quantity) are exceeded, in accordance with Medi-Cal policy, or there is no specific code for the medical supply (that is, a miscellaneous code is needed for billing), or Medi-Cal requires a TAR for the medical supply. A separate, product-specific SAR also is required for DME that exceeds the thresholds for authorization.

DME In addition to what is required by Medi-Cal, the following must be

submitted with a DME SAR for DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment: An Overview.

• Signed prescription by a physician

• HCPCS code



• Model number

• Manufacturer



• Any special features

genetic 10


Medical Supply In addition to what is required by Medi-Cal, the following must be submitted with a medical supply SAR for medical supplies that exceed the billing limits set by Medi-Cal policy:

• Signed prescription by a physician

• HCPCS code(s) DME Modifiers A SAR submitted to the GHPP by a DME or hearing aid provider for

DME that exceeds the thresholds for authorization as referenced in Durable Medical Equipment:: An Overview must contain appropriate modifiers and HCPCS codes. The following modifiers must be included on the SAR, if applicable: NU (new equipment purchase), RR (rental) or RB (replacement as part of a repair) as appropriate.


• The authorized physician treating the GHPP client as an inpatient may proactively request authorization for anticipated post-discharge HHA services at the same time as the inpatient request.

• The physician may request HHA services using a discharge planning SAR. The GHPP program may authorize an initial home assessment and up to three additional visits if requested by a discharging physician at the time of the GHPP client’s discharge from the inpatient stay. For additional medically necessary HHA visits, a SAR and the unsigned plan of treatment must be submitted for authorization.

HHA services not requested on a Discharge Planning SAR, nor requested prior to hospitalization, must be submitted within three working days of the date the services began. Any services provided during this three-day grace period must be included on the SAR. GHPP authorization is contingent on a client’s GHPP program eligibility.

genetic 11


Diagnosis Codes The following is a list of ICD-9-CM diagnosis codes that qualify clients for GHPP. The qualifying GHPP condition is not required in the primary diagnosis field on the claim.

ICD-9-CM Code Description

270.0 Disturbances of amino-acid transport 270.1 Phenylketonuria (PKU) 270.2 Tyrosenemia 270.4 Disturbances of sulphur-bearing amino-acid

metabolism 270.6 Disorders of urea cycle metabolism 271.1 Galactosemia 275.1 Wilson’s disease 277.0 Cystic fibrosis 277.00 Cystic fibrosis, without mention of meconium ileus 277.0 Cystic fibrosis, with meconium ileus 282.4 Thalassemias 282.6 Sickle cell disease 282.60 Sickle cell disease, unspecified 282.61 Hb-SS disease without crisis 282.62 Hb-SS disease with crisis 282.63 Sickle Cell/Hb-C Disease 282.69 Other sickle cell disease with crisis 282.7 Other hemoglobinopathies 286.0 Congenital factor VIII disorder

286.1 Congenital factor IX disorder

286.2 Congenital factor XI disorder

286.3 Congenital deficiency of other clotting factors I, II, V, VII, XII, XIII deficiency

286.4 von Willebrand’s disease

genetic 12


ICD-9-CM Code Description

287.1 Thrombasthenia 287.3 Thrombocytopenia, primary hereditary, congenital 333.0 Olivopontocerebellar degeneration (Dejerine-Thomas

syndrome) 333.4 Huntington’s chorea 334.0 Friedreich’s ataxia 334.1 Hereditary spastic paraplegia 334.3 Roussy-Levy syndrome 356.1 Charcot-Marie-Tooth disease 356.3 Refsum’s disease 759.6 von Hippel-Lindau syndrome

For claims using the Pharmacy Claim Form (30-1) or Compound Drug Pharmacy Claim Form (30-4), ICD-9-CM diagnosis codes are optional.

Hospitalization and Non-contract hospitals that render services to GHPP clients must bill Ancillary Services blood, blood products and physician services separately from

hospitalization. These services, which are ancillary to hospitalization, should be billed on a CMS-1500 claim. Hospitalization is billed on the UB-04 claim.

genetic 13


Managed Care Plans, Medi-Cal contracts with a variety of managed care organizations Private Health Insurance to provide health care on a capitated basis to Medi-Cal recipients and Commercial HMOs residing within specific service areas. Some GHPP clients who are eligible for Medi-Cal reside in these areas and are enrolled in these

Medi-Cal managed care plans.

In such cases the plans are capitated for and are responsible for providing comprehensive health care to these GHPP clients, including services to treat their GHPP eligible conditions. GHPP performs case management and authorizes services for GHPP clients enrolled in Medi-Cal managed care plans in Napa, San Mateo, Santa Barbara, Solano and Yolo counties. Providers must submit claims for authorized services rendered to GHPP/Medi-Cal clients enrolled in these plans to the plan directly.

Similarly, some GHPP clients have private indemnity health insurance, or are enrolled in commercial health maintenance plans or preferred provider organizations. In these cases, GHPP is the health care payer of last resort and will authorize medically necessary services for the GHPP client only after it has been demonstrated that the services are beyond the scope of benefits of the indemnity insurance or health plan. The provider and/or client are required to exercise their appeal rights before GHPP will authorize and reimburse for these services. For information about appeals, refer to the Appeal Process Overview section in the Part 1 – Medi-Cal Program and Eligibility manual.

genetic 14


Claim Submission and Providers must be enrolled in the Medi-Cal program and use their Timeliness Requirements National Provider Identifier (NPI) on all authorized claims for GHPP

clients, regardless of the client’s GHPP eligibility type. An NPI must be used when billing for GHPP/Medi-Cal clients and GHPP-only clients. Hard copy claims are mailed to:

Medi-Cal Fiscal Intermediary PO Box 526006 Sacramento, CA 95852-6006 More information is available in the Claim Submission and Timeliness

Overview section of the Part 1, Medi-Cal Program and Eligibility manual.

Six-Month Billing Limitation Original (or initial) claims must be received by the DHCS Fiscal

Intermediary within six months following the month in which services were rendered. Providers submitting claims after the six-month billing limit must include a valid delay reason code on the claim. A list of valid delay reason codes and additional information is available in the Submission and Timeliness Instructions section of the appropriate Part 2 manual.

Claim payments will be reduced for providers who submit claims after

the six-month billing limit without the required delay reason code. This is in accordance with Medi-Cal policy.

CMC Billing Computer Media Claims (CMC) submission is the most efficient

method of billing. Unlike paper claims, these claims already exist on a computer medium. As a result, manual processing is eliminated. CMC submission offers additional efficiency to providers because claims are submitted faster, entered into the claims processing system faster, and paid faster. For more information, refer to the CMC section of the Part 1 provider manual or call the Telephone Service Center (TSC) at 1-800-541-5555.

Denti-Cal Claims for dental services authorized by GHPP with a SAR number

beginning with a prefix of “99” for GHPP clients must be submitted to Delta Dental for claim processing.

genetic 15


Remittance Advice Details Standard Medi-Cal procedures apply for provider warrants and and Warrants Remittance Advice Details (RADs). For more information, refer to the

Remittance Advice Details (RADs): Payments and Claims Status section in this manual.

Claims Inquiry Forms A Claims Inquiry Form (CIF) must be used as a tracer for a GHPP

Medi-Cal claim if the claim has not appeared on a RAD 60 days after submission to the GHPP state office. A CIF cannot be used to trace a GHPP claim billed for a non Medi-Cal eligible GHPP client. If such a claim does not appear on a RAD after 60 days, providers should contact the Telephone Service Center (TSC) at 1-800-541-5555.

For further information about CIFs and tracers, providers may refer to the CIF Overview section in the Part 1 – Medi-Cal Program and Eligibility manual.

Resubmission Turnaround A Resubmission Turnaround Document (RTD) may be generated by Documents the DHCS Fiscal Intermediary and sent to providers when a submitted

GHPP claim has questionable or missing information. Returning a completed RTD to the DHCS FI may eliminate the need to resubmit the entire claim to correct certain errors.

Completed RTDs may be mailed to the DHCS FI at the following address:

HP Enterprise Services P.O. Box 15200 Sacramento CA 95815-1200

hcpcs HCPCS Introduction 1

2 – HCPCS Introduction March 2009

This section describes the HCPCS coding system and how it is used under the Medi-Cal program. HCPCS The Healthcare Common Procedure Coding System (HCPCS) is a

national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to process Medicare and Medicaid (Medi-Cal) claims on a national basis.

HCPCS is a three-level coding system that incorporates Physicians’ Current Procedural Terminology (CPT-4), National and Local codes. Medi-Cal implemented CPT-4 coding (Level I) for physician services in November 1987. HCPCS National Level II codes (formerly SMA codes; non-physician procedures and services) and HCPCS Local Level III codes (California-only) were implemented for services provided on or after October 1, 1992. This implementation completed Medi-Cal’s conversion from SMA codes to HCPCS codes.

HCPCS Coding Format The HCPCS coding format for Level I is five-digit numeric. The format

for Level II and III is an alpha character followed by four numeric digits. The full range of codes for each level is as follows: Level I is 00100 thru 01999 and 10000 thru 99999; Level II is A0000 thru V9999; Level III is W0000 thru Z9999 (Medi-Cal Level III codes are prefixed with alpha character X or Z; Medicare carrier Level III codes are prefixed with alpha character W or Y).

Level II and Level III Codes The existence of a specific Level II HCPCS code in the HCPCS book

for a particular item or service is not a guarantee that the item or service is covered by Medi-Cal. Refer to the section specific to the service rendered for Medi-Cal reimbursable Level II and III HCPCS codes.

Modifier Coding Format Modifiers for each level are as follows: Level I is 01 thru 99; Level II is

AA thru VP and A1 thru V9; Level III is WA thru ZZ and W1 thru Z9 (Medi-Cal-only modifier ranges are YV thru YX, Z1 thru Z9, and ZA thru ZZ).

hcpcs 2

2 – HCPCS Introduction March 2009

HCPCS Billing Exceptions Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) and L.A. Waiver facility providers must bill services with two-digit billing codes. FQHCs and RHCs are reimbursed consistent with a Prospective Payment System (PPS). (The PPS replaced reasonable cost-based reimbursement.) Los Angeles County facilities operate under a Federal waiver.

Ophthalmological and Ophthalmological services are billed on the CMS-1500 claim. Professional Services Eye Appliances Eye appliances must be billed on the CMS-1500 claim with the

appropriate modifier, as needed.

Medical Supplies Medical supplies must be billed using the appropriate HCPCS Level II

code. Medical supply codes (format of four numeric digits followed by an alpha character: 9900A – 9900Z) must not be used.

hcpcs 3

2 – HCPCS Introduction April 2003

HCPCS Books Providers may order HCPCS (Level II) books from:

Ingenix P.O. Box 27116 Salt Lake City, UT 84127-0116 Telephone: 1-800-765-6588 (Customer service)

Or

PMIC (Practice Management Information Corporation) Order Processing Department 4727 Wilshire Boulevard, Suite 300 Los Angeles, CA 90010-3894 Telephone: 1-800-MED-SHOP (Monday – Friday, 8:00 a.m. – 5:30 p.m., CST) Fax: (630) 964-8873 (24 hours daily) (For credit card orders or purchase orders)

Or

American Medical Association Order Department P.O. Box 930876 Atlanta, GA 31193-0876 Telephone: 1-800-621-8335 Fax: (312) 464-5600

Medi-Cal HCPCS Providers should refer to the HCPCS code books for the exact Benefits descriptions of Level II codes or refer to the appropriate policy

sections of this provider manual for Level III code descriptions. Codes listed in the HCPCS Level II code books are not necessarily benefits of the Medi-Cal program.

Note: The HCPCS Level III List: Reimbursable Medi-Cal-Only Codes section in this manual should be used as a reference to determine if there is a Medi-Cal Level III HCPCS code that may

be billed for a service. The respective policy sections contain specific descriptions concerning the Level III codes.

It is the provider’s responsibility to ensure that the procedure code

billed is appropriate for the service rendered.

hcpcs HCPCS Introduction 1

2 – HCPCS Introduction February 2009

This section describes the HCPCS coding system and how it is used under the Medi-Cal program. HCPCS The Healthcare Common Procedure Coding System (HCPCS) is a

national, uniform coding structure developed by the Centers for Medicare & Medicaid Services (CMS) to standardize the coding systems used to process Medicare and Medicaid (Medi-Cal) claims on a national basis.

HCPCS is a three-level coding system that incorporates Physicians’ Current Procedural Terminology (CPT-4), National and Local codes. Medi-Cal implemented CPT-4 coding (Level I) for physician services in November 1987. HCPCS National Level II codes (formerly SMA codes; non-physician procedures and services) and HCPCS Local Level III codes (California-only) were implemented for services provided on or after October 1, 1992. This implementation completed Medi-Cal’s conversion from SMA codes to HCPCS codes.

HCPCS Coding Format The HCPCS coding format for Level I is five-digit numeric. The format

for Level II and III is an alpha character followed by four numeric digits. The full range of codes for each level is as follows: Level I is 00100 thru 01999 and 10000 thru 99999; Level II is A0000 thru V9999; Level III is W0000 thru Z9999 (Medi-Cal Level III codes are prefixed with alpha character X or Z; Medicare carrier Level III codes are prefixed with alpha character W or Y).

Level II and Level III Codes The existence of a specific Level II HCPCS code in the HCPCS book

for a particular item or service is not a guarantee that the item or service is covered by Medi-Cal. Refer to the section specific to the service rendered for Medi-Cal reimbursable Level II and III HCPCS codes.

Note: Medical supply codes (format of four numeric digits followed by

an alpha character: 9900A – 9900Z series codes) are not considered HCPCS codes.

Modifier Coding Format Modifiers for each level are as follows: Level I is 01 thru 99; Level II is

AA thru VP and A1 thru V9; Level III is WA thru ZZ and W1 thru Z9 (Medi-Cal-only modifier ranges are YV thru YX, Z1 thru Z9, and ZA thru ZZ).

Effective for Dates of Service On or Before March 31, 2009

hcpcs 2

2 – HCPCS Introduction May 2007

HCPCS Billing Exceptions Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) and L.A. Waiver facility providers must bill services with two-digit billing codes. FQHCs and RHCs are reimbursed consistent with a Prospective Payment System (PPS). (The PPS replaced reasonable cost-based reimbursement.) Los Angeles County facilities operate under a Federal waiver.

Ophthalmological and Ophthalmological services are billed on the CMS-1500 claim. Professional Services Eye Appliances Eye appliances must be billed on the CMS-1500 claim with the

appropriate modifier, as needed.


hcpcs 3

2 – HCPCS Introduction April 2003

HCPCS Books Providers may order HCPCS (Level II) books from:

Ingenix P.O. Box 27116 Salt Lake City, UT 84127-0116 Telephone: 1-800-765-6588 (Customer service)

Or

PMIC (Practice Management Information Corporation) Order Processing Department 4727 Wilshire Boulevard, Suite 300 Los Angeles, CA 90010-3894 Telephone: 1-800-MED-SHOP (Monday – Friday, 8:00 a.m. – 5:30 p.m., CST) Fax: (630) 964-8873 (24 hours daily) (For credit card orders or purchase orders)

Or

American Medical Association Order Department P.O. Box 930876 Atlanta, GA 31193-0876 Telephone: 1-800-621-8335 Fax: (312) 464-5600

Medi-Cal HCPCS Providers should refer to the HCPCS code books for the exact Benefits descriptions of Level II codes or refer to the appropriate policy

sections of this provider manual for Level III code descriptions. Codes listed in the HCPCS Level II code books are not necessarily benefits of the Medi-Cal program.

Note: The HCPCS Level III List: Reimbursable Medi-Cal-Only Codes section in this manual should be used as a reference to determine if there is a Medi-Cal Level III HCPCS code that may

be billed for a service. The respective policy sections contain specific descriptions concerning the Level III codes.

It is the provider’s responsibility to ensure that the procedure code

billed is appropriate for the service rendered.


HCPCS Level III Interim Code List: Reimbursable hcpcs iii Medi-Cal-Only Codes 1

2 – HCPCS Level III Interim Code List: Reimbursable Medi-Cal-Only Codes June 2010

This section identifies the HCPCS Local Level III interim codes reimbursable only by Medi-Cal and includes the type of service, the first code in the code range assigned to the service and the provider community that may bill the service. The entire code range is not listed because not all codes within the code range are current Medi-Cal benefits. Providers should refer to the appropriate Medi-Cal provider manual for specific policy and billing codes.

Type of Service Interim Code Range First Code

Provider Type

Cancer Detection Programs: Every Woman Counts

X7700 Z7500 Z7600

Medical, Outpatient

California Children’s Services (CCS) and Genetically Handicapped Persons Program (GHPP) Services

Z5400 Inpatient, Medical, Outpatient

Child Health and Disability Prevention (CHDP) and Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Z5800 Medical, Outpatient

Comprehensive Perinatal Services

Nutrition Services Z6200 Medical, Outpatient Psychosocial Services Z6300 Medical, Outpatient Health Education Services Z6400 Medical, Outpatient Other Z6500 Medical, Outpatient

hcpcs iii 2

2 – HCPCS Level III Interim Code List: Reimbursable Medi-Cal-Only Codes June 2010


Provider Type

Dialysis (Chronic) Facility Services Z6000 Medical, Outpatient

Drugs, Oral and Non-Oral Chemotherapy Drugs X7500 Inpatient, Medical Injections X5500 Inpatient, Medical, Outpatient Other X7700 Inpatient, Medical, Outpatient

Family PACT (Medi-Cal-Only) Z9750 Medical, Outpatient

Genetic Disease Newborn Screening


Heroin Detoxification, Outpatient H0014 Outpatient

Home Health Agencies Z6900 Outpatient

Hospice Care Z7100 Outpatient

hcpcs iii 3

2 – HCPCS Level III Interim Code List: Reimbursable Medi-Cal-Only Codes March 2009


Provider Type

Multi-Purpose Senior Services Program (MSSP)

Z8550 Outpatient

Newborn Hearing Screening Program


Organ Procurement Services Z7300 Medical

Outpatient Services Room Use Codes Z7500 Outpatient Other Z7600 Outpatient

Personal Care Services Program Z9525 Medical, Outpatient

Physician Anesthesia Z0800 Inpatient, Medical, Outpatient Medicine Genetic Counseling Z0000 Medical, Outpatient Multiple Patient Visit Codes Z0200 Inpatient, Medical, Outpatient Neonatal Intensive Care Z0100 Inpatient, Medical, Outpatient Subacute Care X9900 Allied Health, Inpatient, Medical,

Outpatient Other Z0300 Allied Health, Inpatient, Medical,

Outpatient Surgery Other Z1200 Inpatient, Medical, Outpatient

hcpcs iii 4

2 – HCPCS Level III Interim Code List: Reimbursable Medi-Cal-Only Codes November 2008


Provider Type

Psychology X9500 Allied Health

Rehabilitation Services Audiology X4500 Allied Health, Medical, Outpatient Occupational Therapy X4100 Allied Health, Medical, Outpatient Physical Therapy X3900 Allied Health, Medical, Outpatient Speech Pathology X4300 Allied Health, Medical, Outpatient

Supplies (Medical and Surgical) X1500 Inpatient, Medical, Outpatient

Transportation Services Air Transportation X0504 Allied Health Ambulance X0000 Allied Health Hospital To Long Term Care (LTC) Transfer

X0400 Allied Health

Wheelchair and Litter Van X0200 Allied Health

loc ed Local Educational Agency (LEA) 1

2 – Local Educational Agency (LEA) Outpatient Services – LEA 437 February 2011

This section contains a brief overview of the Local Educational Agency (LEA) Medi-Cal Billing Option Program and contact information that providers may use to obtain additional information about the program. Overview of LEA The Local Educational Agency (LEA) Medi-Cal Billing Option Program

offers health assessment and treatment for eligible students and eligible family members within the school environment. The following manual sections contain LEA policy and billing instructions.

• LEA: A Provider’s Guide

• LEA Billing and Reimbursement Overview

• LEA Billing Codes and Reimbursement Rates

• LEA Billing Examples

• LEA Eligible Students

• LEA Individualized Plans

• LEA Rendering Practitioner Qualifications

• LEA Service: Hearing

• LEA Service: Nursing

• LEA Service: Occupational Therapy

• LEA Service: Physical Therapy

• LEA Service: Physician Billable Procedures

• LEA Service: Psychology/Counseling

• LEA Service: Speech Therapy

• LEA Service: Targeted Case Management

• LEA Service: Transportation (Medical)

• LEA Service: Vision Assessments

loc ed 2

2 – Local Educational Agency (LEA) Outpatient Services – LEA 437 February 2011

Inquiries LEA providers and billing vendors may obtain information from the following resources.

Billing Questions

DHCS Fiscal Intermediary (FI) 1-800-541-5555 DHCS FI (Out-of-State Billers) (916) 636-1200

Program and Policy Questions

Department of Health Care Services (DHCS) Medi-Cal Benefits Branch [email protected]

Or write to:

Department of Health Care Services Safety Net Financing Division MS 4603 P.O. Box 997436 Sacramento, CA 95899-7436

Provider Participation Agreement Requests/ Provider Enrollment Questions

California Department of Education, (CDE), Healthy Start (916) 319-0298 DHCS Provider Enrollment Division (916) 323-1945

Eligibility Data Match Questions

DHCS Information Technology (916) 440-7253 Services Division

LEA Reinvestment Questions

CDE, Healthy Start (916) 319-0284

Interim Reimbursement and Units of Service (IRUS) Report Request [email protected]

Cost and Reimbursement Comparison Schedule (CRCS) Questions [email protected]

CRCS Submission [email protected] Additional Information Additional information may be obtained at the LEA Program website, www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx and the Medi-Cal website, www.medi-cal.ca.gov.

Local Educational Agency (LEA): loc ed a prov A Provider’s Guide 1

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 401 February 2008

This section contains information about how Local Educational Agencies (LEAs) enroll to participate in the Local Educational Agency Medi-Cal Billing Option Program. Also included is information about LEA provider responsibilities, service and reimbursement reports, and models that LEAs may follow to effectively provide Medi-Cal services. Provider Enrollment Local Educational Agencies (LEAs), as defined under California

Education Code, Section 33509(e), may apply to participate in this program. Applications are available from the following:

• California Department of Education (CDE) Healthy Start Office

at the telephone number identified in the Local Educational Agency (LEA) section of this manual

• Department of Health Care Services (DHCS) Provider Enrollment Division (PED) at the telephone number identified in the Local Educational Agency (LEA) section of this manual

• LEA Program Web site, www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx

An LEA provider (usually a school district or county office of education)

must complete the following documents to apply for participation in the LEA Program:

• Local Educational Agency (LEA) Medi-Cal Provider Enrollment Information Sheet. This form is used by DHCS to create a Provider Master File (PMF), which is used by the Medi-Cal program to identify currently enrolled, valid Medi-Cal providers and to identify the services for which they are eligible to receive reimbursement under Medi-Cal.

• Local Educational Agency (LEA) Medi-Cal Billing Option Provider Participation Agreement. This contract sets out responsibilities relative to participation in the LEA Medi-Cal Billing Option, including LEA provider and DHCS responsibilities, agreement activation and termination.

• Certification of State Matching Funds for LEA Services. This certification must be completed annually, first with the contract itself and subsequently as part of the annual report. It certifies that the State funds match for LEA payments will be made from LEA funds rather than the State General Fund.

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2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 413 February 2009

• Statement of Commitment to Reinvest. This statement certifies that a local collaborative has been formed and includes among its responsibilities reinvestment of funds made available through participation in the LEA Medi-Cal Billing Option. With this form, the LEA certifies that reinvested funds will remain within the school-linked support services identified in provision 7 of the Local Educational Agency (LEA) Medi-Cal Billing Option Provider Participation Agreement.

Provisions 7, 8 and 9 of the Local Educational Agency (LEA) Medi-Cal Billing Option Provider Participation Agreement

(available at www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx) contain additional information about local collaboratives and

reinvestment of federal funds. Provider Responsibilities LEA provider responsibilities include the following:

• Complying with California Welfare and Institutions Code (W&I Code), Chapter 7 (commencing with Section 14000); and in some cases, with Chapter 8 (commencing with Section 14200); California Code of Regulations (CCR), Title 22, Division 3 (commencing with Section 50000); and California Education Code, Articles 1, 2, 3, 4, 4.5 and 15 and Sections 8800 and 49400; all as periodically amended.

• Billing only for LEA services rendered by qualified medical care

practitioners within the practitioner’s defined scope of practice. A list of the health professionals who are qualified rendering practitioners and the specific qualifications those practitioners must meet are included in the Local Educational Agency (LEA) Rendering Practitioner Qualifications section of this manual.

• Billing for reimbursement of Targeted Case Management

(TCM) services only if enrolled as an LEA provider and meeting case manager qualifications. The qualifications are set forth in CCR, Title 22, Section 51271.

LEA providers who want to bill for TCM services must complete the LEA Targeted Case Management Labor Survey. This survey is used by the DHCS Safety Net Financing Division to determine the TCM reimbursement rate (low, medium or high). This form must be submitted to DHCS prior to submitting TCM claims. The form is available through the DHCS Safety Net Financing Division e-mail or postal address listed in the Local Educational Agency (LEA) section of this manual or at the LEA Program Web site, www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx.

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2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 421 October 2009

• Submitting a Cost and Reimbursement Comparison Schedule (CRCS) to DHCS each year. See “Cost and Reimbursement Comparison Schedule (CRCS)” in this section for more information.

• Submitting an annual report to DHCS by October 30 of each

year as required in the Local Educational Agency (LEA) Medi-Cal Billing Option Provider Participation Agreement. Providers may refer to the annual report for additional information or contact the Provider Enrollment Division at the telephone number listed in the Local Educational Agency (LEA) section of this manual. See “Annual Report Requirements” and “Where to Submit Annual Reports” in this section for more information.

Annual Report Requirements The annual report contains data concerning expenditures and activities

for the preceding fiscal year (July 1 through June 30) and service priorities for the current fiscal year.

A current electronic version of the annual report is available online for

providers prior to the due date, October 30, at the program Web site, www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx. Continued

enrollment is contingent upon submission of the annual report. The annual report must include:

• A list of the agencies and entities participating in the

collaborative.

• A description of the collaborative and decision-making process, including frequency of collaborative meetings.

• A summary financial statement for the previous fiscal year

identifying funds received and funds reinvested, including collaboration, case management and claims processing costs.

• A detailed explanation of use, or plans for use, of any funds not

accounted for in the summary financial statement for the previous fiscal year.

• Anticipated service priorities for the current fiscal year.

• A Certification of State Matching Funds for LEA Services. This

form is mailed to providers prior to the due date.

• A Statement of Commitment to Reinvest.

loc ed a prov 4

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 421 October 2009

Where to Submit Annual reports should be mailed to the following address: Annual Reports Department of Health Care Services Provider Enrollment Division MS 4704 P.O. Box 997413 Sacramento, CA 95899-7413 Cost and Reimbursement Under the LEA Medi-Cal Billing Option, LEA providers must Comparison Schedule (CRCS) annually certify in a Cost and Reimbursement Comparison Schedule

(CRCS) that the public funds expended for services provided have been expended as necessary for federal financial participation pursuant to the requirements of Social Security Act, Section 1903(w) and Code of Federal Regulations (CFR), Title 42, Section 433.50, et seq. for allowable costs. The CRCS is used to compare each LEA’s actual costs for LEA services to the interim Medi-Cal reimbursement for the preceding fiscal year.

CRCS reports are based on a comparison of LEA health service costs

to interim Medi-Cal reimbursements for each fiscal year, July 1 to June 30. An Interim Reimbursement and Units of Service Report is mailed to LEAs prior to the date that the CRCS is due to DHCS. The interim report includes information needed to complete the CRCS.

Current CRCS versions are available at the LEA Program Web site, www.dhcs.ca.gov/ProvGovPart/Pages/LEA.aspx.

Continued enrollment in the LEA Program is contingent upon

submission of a CRCS. LEAs Responsible for Information about LEA provider responsibility to maintain documented Maintaining Evidence of evidence of rendering practitioners’ qualifications is included under Practitioner Qualifications “Documenting Practitioner Qualifications” in the Local Educational

Agency (LEA) Rendering Practitioner Qualifications section of this manual.

loc ed a prov 5

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 418 July 2009

Models of Service LEAs may employ or contract with qualified medical care practitioners Delivery for Employed to provide LEA services to Medi-Cal eligible students and their or Contracted families. The following models describe the type of arrangements in Practitioners which LEAs may choose to provide Medi-Cal services. Model 1: Direct Employment of Health Care Practitioners The LEA employs health care practitioners to provide health services

to LEA students. The LEA bills and receives Medi-Cal payments for the covered services provided.

Model 2: Contracting of Health Care Practitioners or Clinics The LEA contracts with health care practitioners or clinics to provide

health services to LEA students. The health care practitioner or clinic (not the LEA) is considered the provider of services. The LEA does not bill to or receive Medi-Cal payments for services. For the LEA provider to bill and receive Medi-Cal reimbursement for the covered services, the provider of services must voluntarily reassign their right to payment to the LEA. Under these circumstances, the LEA provider may then bill for the services rendered.

The practitioner must be separately qualified and enrolled as a

Medicaid provider and must have a separate provider number. In addition, assignment to the school must be accomplished in a way that satisfies all applicable federal requirements. For example, in accepting assignment of Medicaid claims, the school also accepts the providers’ responsibility for billing and collecting from Other Health Coverage and third party payers.

Model 3: Direct Employment and Contracting with Health Care

Practitioners to Supplement Services The LEA uses a combination of employed and contracted health care

practitioners to render health services to LEA students. In addition, to supplement health services that are already being rendered by their own employees, LEAs contract with additional health professionals. The services rendered by the additional health professionals must be the same as those offered by LEA practitioners. For example, the LEA may employ one physical therapist and contract with other physical therapists to supply additional physical therapy services. The LEA bills and receives Medi-Cal payments for covered services provided.

Additional information is available in the Federal Centers for Medicare

& Medicaid Services (CMS) Medicaid and School Health: Technical Assistance Guide, August 1997, available at www.dhcs.ca.gov/ ProvGovPart/Documents/ACLSS/LEA/SCBGuide.pdf.

loc ed a prov 6

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 418 July 2009

Managed Care Plans Managed Care Plans (MCPs) include Prepaid Health Plans (PHPs), County Health Initiatives, Special Projects and Primary Care Case Management (PCCM) contractors.

Services rendered under the LEA Program to students who are also

members of a Medi-Cal MCP are:

• Reimbursable to the LEA for students whose Individualized Education Plans (IEPs) or Individualized Family Services Plans (IFSPs) authorize the service and the service is documented as medically necessary. MCPs are not capitated for LEA services and services may be rendered beyond the 24 LEA services per state fiscal year.

• Reimbursable to the LEA but limited to 24 LEA services

(assessment, treatment or transportation) per state fiscal year for services that are not authorized in an IEP or IFSP. The state fiscal year begins on July 1 of each year.

LEAs may contract with managed health care providers to render

health care services separate and distinct from LEA services if mutually agreeable terms can be reached that do not create additional costs for the State.

Note: The term “MCP” is used interchangeably with “HCP” (Health

Care Plan). For example, recipient eligibility messages use HCP, while manual pages use both HCP and MCP. Additional information about MCPs is included in the MCP sections of the Part 1 Medi-Cal manual.

Free care and Other Health Coverage (OHC) requirements

apply to services rendered to students who are members of a Medi-Cal MCP and billed to the LEA Program.

loc ed a prov 7

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 379 May 2006

Records Retention LEA providers must keep, maintain and have available records that fully disclose the type and extent of LEA services provided to Medi-Cal recipients. The required records must be made at or near the time the service was rendered (California Code of Regulations [CCR], Title 22, Section 51476).

Each service encounter with a Medi-Cal eligible student must be

documented as follows:

• Date of service • Name of student • Student’s Medi-Cal identification number • Name of agency rendering the service • Name of person rendering the service • Nature, extent, or units of service • Place of Service

Required supporting documentation describing the nature or extent of

service includes, but is not limited to the following:

• Progress and case notes • Contact logs • Nursing and health aide logs • Transportation trip logs • Assessment reports

For LEA services that are authorized in a student’s IEP or IFSP, a

copy of the IEP or IFSP that identifies the child’s need for health services and the associated IEP/IFSP assessment reports must be maintained in the provider’s files. LEA services must be billed according to the provisions of the student’s IEP or IFSP, including service type(s), number and frequency of LEA services, and length of treatments, as applicable.

For audit purposes, LEA Targeted Case Management providers must

retain the following:

• Service plan • Documentation of case management activities • Records containing a review of student and/or family progress

LEAs must keep records of current credentials and licenses for all

employed or contracted practitioners. Prescriptions, referrals or recommendations must also be documented in the student’s files. Other documentation includes claim forms and billing logs, Other Health Coverage (OHC) information, if any, and claim denials from OHC insurance carriers.

loc ed a prov 8

2 – Local Educational Agency (LEA): A Provider’s Guide Outpatient Services – LEA 435 December 2010

Medi-Cal requires LEA providers to:

• Agree to keep necessary records for a minimum of three years from the date of submission of the CRCS to report the full extent of LEA services furnished to the student (W&I Code, Section 14170).

• Keep, maintain and have available CRCS supporting financial and service documentation at a minimum, until the auditing process of the Medi-Cal CRCS has been completed. If an audit and/or review is in process, LEA providers shall maintain documentation until the audit/review is completed, regardless of the three-year record retention time frame.

• Furnish these records and any information regarding payments claimed for rendering the LEA services, on request, to DHCS; Bureau of Medi-Cal Fraud, California Department of Justice; DHCS Audits and Investigations; Office of State Controller; U.S. Department of Health and Human Services; and any other regulatory agency or their duly authorized representatives.

• Certify that all information included on the printed copy of the original document is true, accurate and complete.

In addition, for record keeping purposes LEA providers should carefully review the full text of W&I Code, Chapter 7 (commencing with Section 14000) and, in some cases, Chapter 8. Other record

keeping requirements of the Medi-Cal program are found in the Provider Regulations section of the Part 1 Medi-Cal provider manual.

Support Cost A 1 percent administrative fee is levied against LEA claims for claims

processing and related costs and an additional 2.5 percent to fund activities mandated by Senate Bill 231 (Chapter 655, Statutes of 2001). The annual amount of the 2.5 percent withhold is not to exceed $1,500,000. The fees are subtracted from the total reimbursement amount on the Medi-Cal Remittance Advice Details (RAD) with RAD code 795 for the 1 percent withhold and code 798 for the 2.5 percent withhold.

Service and Reimbursement Each month, LEAs that have submitted Medi-Cal claims receive a Report service and reimbursement report from the DHCS Fiscal Intermediary

(FI). The report lists the number of services rendered, dollar amounts reimbursed and the procedure codes paid. Fiscal data is listed by month, quarter-to-date and year-to-date on a state fiscal year basis (July 1 – June 30).

Local Educational Agency (LEA) Billing loc ed bil and Reimbursement Overview 1

2 – Local Educational Agency (LEA) Outpatient Services – LEA 391 Billing and Reimbursement Overview May 2007

This section contains information about reimbursable services for the Local Educational Agency (LEA) Medi-Cal Billing Option Program and how to bill for those services. Included is information about non-reimbursable services, when to bill Other Health Coverage (OHC), and identification of the services each type of practitioner may bill. Also included is information about the type of claim form on which to bill, claim completion instructions and where to submit the claim. Introduction LEA providers may bill for services rendered to Medi-Cal eligible

students. LEA services may be billed on the paper UB-04 claim or submitted electronically through Computer Media Claims (CMC). (See “Computer Media Claims [CMC] in this section for more information.)

Billing Code List A complete list of procedure codes that are reimbursable to LEAs for

assessment, treatment, Targeted Case Management (TCM) and transportation services is included in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual.

Restrictions Time billed for treatments should include only direct service time.

Indirect service time has been included in the reimbursement rate and should not be billed. Medi-Cal will not reimburse providers for services that are mandated by state law.

loc ed bil 2

2 – Local Educational Agency (LEA) Outpatient Services – LEA 418 Billing and Reimbursement Overview July 2009

Free Care and Other Health Med-Cal will not reimburse LEA providers for services provided to Coverage Requirements Medi-Cal recipients if the same services are offered for free to

non-Medi-Cal recipients. LEA providers must use specific methods to ensure the care is not considered free, allowing Medi-Cal to be billed.

For LEA services provided to Medi-Cal eligible students to be reimbursable, the LEA must:

1. Establish a fee for each service provided (it could be sliding

scale to accommodate individuals with low income); 2. Collect Other Health Coverage (OHC) information from all those

served (Medi-Cal and non-Medi-Cal); and 3. Bill other responsible third party insurers.

The following chart clarifies when OHC insurers must be billed:

Insurance Status

of Student

Services Provided to Students Authorized in

an IEP/IFSP or Under Title V*

Eligible Services Provided to

All Other Students

Medi-Cal only Bill Medi-Cal Bill Medi-Cal

Medi-Cal and OHC Bill OHC, then Medi-Cal Bill OHC, then Medi-Cal

No Medi-Cal, has OHC Don’t have to bill OHC Must bill OHC

* Title V of the Social Security Act – Grants for States for Maternal and Child Welfare

The LEA must request OHC information for all students served, obtain a 100 percent response rate, and bill OHC insurers of Medi-Cal and non-Medi-Cal students prior to billing Medi-Cal. For Medi-Cal eligible students, OHC information can be obtained from the data layout displayed during the Internet eligibility verification process. Additional information about this Medi-Cal Web site Internet option and ways to verify eligibility is available in the Local Educational Agency (LEA): Eligible Students section of this manual.

loc ed bil 3


If any parent refuses to allow the OHC to be billed, and the LEA service is still provided, it is considered free care and precludes the LEA from billing Medi-Cal for that type of service to any student.

Example Many schools have a school nurse on staff to provide necessary

health services to all students without charging them for the care provided. The school must not bill Medi-Cal for LEA services provided by the school nurse that are not authorized in an IEP, IFSP or under Title V if the nurse provides LEA services to all students (not solely Medi-Cal eligible) without also billing OHC for non-Medi-Cal students.

Exceptions to the Free Medi-Cal covered services, provided under an IEP, IFSP or Title V, Care Requirement are exempt from the free care requirement. Although the services are

exempt from the free care requirement, the LEA provider still must bill OHC insurers of Medi-Cal students for reimbursement before billing Medi-Cal.

Example A Medi-Cal eligible student with OHC is provided speech therapy that

is documented in the student’s IEP/IFSP. The LEA provider must pursue recovery from the OHC insurers for reimbursement before billing Medi-Cal.

State Mandated LEAs are legally obligated to provide and pay for services that are Assessments: mandated by state law, such as state mandated screenings. Services Not Reimbursable provided by LEAs that are mandated by state law are not reimbursable

and must not be billed to Medi-Cal. Examples Example: A child is referred by a teacher for a vision assessment

(outside of the mandated periodicity schedule) because he may not be seeing the blackboard clearly. Because the vision test is not mandated by state law, Medi-Cal may be billed for services rendered to this child if the LEA performs all of the following:

• Requests OHC information for all students served • Obtains a 100 percent response rate • Bills all OHC insurers of Medi-Cal and non-Medi-Cal

children for this service Example: An IEP child receives a non-IEP assessment that is

mandated by state law. Medi-Cal must not be billed, because this assessment is state mandated and is given free of charge to any student.

loc ed bil 4

2 – Local Educational Agency (LEA) Outpatient Services – LEA 423 Billing and Reimbursement Overview December 2009

Other Health If the OHC carrier denies a claim, the denial notice is valid and may Coverage Denials be submitted with Medi-Cal claims for one year from the date of the

denial for that student and procedure. LEA providers are subject to the same denial criteria as other Medi-Cal providers. That is, a claim

will be processed by the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) only if the denial reason listed on the Explanation of Benefits (EOB) or denial letter is a valid denial reason

according to Medi-Cal standards. Legitimate denial reasons may include, but are not limited to:

• Service not covered • Patient not covered • Deductible not met

Non-legitimate denial reasons generally involve improper billing, such

as submitting a late, incorrect or illegible claim. The following provider manual sections contain OHC codes,

information about identifying student OHC and other general OHC billing information that LEAs need to submit Medi-Cal claims:

• Other Health Coverage (OHC) Codes Chart in the Part 1

manual • Other Health Coverage (OHC) Guidelines for Billing in the

Part 1 manual • Other Health Coverage (OHC) section in this manual

loc ed bil 5


Managed Care Plans Information about reimbursement of services for students who are members of Medi-Cal Managed Care Plans (MCPs) is available in the Local Educational Agency (LEA): A Provider’s Guide section of this manual.

Practitioner Services The two charts on following pages in this section are quick reference Reimbursable to LEAs guides to help LEA providers identify the qualified rendering

practitioners who may perform each LEA service. The charts also list additional service requirements; for example, when supervision is required.

• Practitioner-Performed Assessment Services Reimbursable

to LEAs

• Practitioner-Performed Treatment and TCM Services Reimbursable to LEAs

loc ed bil 6


Practitioner-Performed Assessment Services Reimbursable to LEAs

IEP/IFSP ASSESSMENTS NON-IEP/IFSP ASSESSMENTS

Practitioner Psy

chol

ogic

al

Psy

chos

ocia

l

Sta

tus

Hea

lth

Hea

lth/N

utrit

ion

Aud

iolo

gica

l

Spe

ech-

Lang

uage

Phy

sica

l The

rapy

Occ

upat

iona

l T

hera

py

Psy

chos

ocia

l S

tatu

s

Hea

lth/N

utrit

ion

Hea

lth E

duca

tion/

A

ntic

ipat

ory

G

uida

nce

Hea

ring

(1)

Vis

ion

(1)

Dev

elop

men

tal

Registered Credentialed School Nurse X(6) X(6) X(6) X(6)

Licensed Physician/Psychiatrist X(6) X(6) X(6) X(6) X(6)

Licensed Optometrist X(6) Licensed Clinical

Social Worker X(5) X(5) X(5) Credentialed School

Social Worker X(5) X(5) X(5)

Licensed Psychologist X(5) X(5) X(5) Licensed Educational

Psychologist X(5) X(5) X(5) Credentialed School

Psychologist X(5) X(5) X(5) Licensed Marriage and

Family Therapist X(5) X(5) X(5) Credentialed School

Counselor X(5) X(5) X(5) Licensed Physical

Therapist X(3) X(3) Registered Occupational

Therapist X(3) X(3) Licensed Speech-

Language Pathologist X(4) X(4) X(4) Speech-Language

Pathologist X(2)(4) X(2)(4) X(2)(4)

Licensed Audiologist X(4) X(4)

Audiologist X(2)(4) X(2)(4) Registered School

Audiometrist X(4)

Notes: (1) State mandated assessments (hearing, vision and scoliosis) are not reimbursable under the LEA Program. (2) Requires supervision. (3) Requires a written prescription by a physician or podiatrist, within the practitioner’s scope of practice. In substitution of a written prescription, a registered credentialed school nurse, teacher or parent may refer the student for the assessment. (4) Requires a written referral by a physician or dentist, within the practitioner’s scope of practice. In substitution of a written referral, a registered credentialed school nurse, teacher or parent may refer the student for the assessment. (5) Requires a recommendation by a physician, registered credentialed school nurse, licensed clinical social worker, licensed psychologist, licensed educational psychologist, or licensed marriage and family therapist, within the practitioner’s scope of practice. In substitution of a recommendation, a teacher or parent may refer the student for the assessment. (6) Requires a recommendation by a physician or registered credentialed school nurse. In substitution of a recommendation, a teacher or parent may refer the student for the assessment.

General Note: Credentialing requirements for licensed practitioners employed by LEAs are described in the Local Educational Agency (LEA) Rendering Practitioner Qualifications section of this manual.

loc ed bil 7

2 – Local Educational Agency (LEA) Outpatient Services – LEA 413 Billing and Reimbursement Overview February 2009

Practitioner-Performed Treatment and TCM Services Reimbursable to LEAs

Practitioner Phys

ical

Th

erap

y

Occ

upat

iona

l Th

erap

y

Spee

ch

Ther

apy

Aud

iolo

gy

(incl

udin

g H

earin

g C

heck

)

Psyc

holo

gy

and

Cou

nsel

ing

Nur

sing

Se

rvic

es

Scho

ol H

ealth

A

ide

Serv

ices

Targ

eted

Cas

e M

anag

emen

t

Registered Credentialed School Nurse X X

Certified Public Health Nurse X(6) X Licensed RN and Certified

Nurse Practitioner X(5) X

Licensed Vocational Nurse X(1) X Trained Health Care Aide X(1)

Licensed Physician/Psychiatrist X Licensed Clinical Social Worker X(4) X

Credentialed School Social Worker X(4) X

Licensed Psychologist X(4) X Licensed Educational Psychologist X(4) X Credentialed School Psychologist X(4) X

Licensed Marriage and Family Therapist X(4) X

Credentialed School Counselor X Licensed Physical Therapist X(2)

Registered Occupational Therapist X(2) Licensed Speech-Language

Pathologist X(3)

Speech-Language Pathologist X(1)(3) Licensed Audiologist X(3)

Audiologist X(1)(3) Program Specialist X

Notes: (1) Requires supervision. (2) Requires a written prescription by a physician or podiatrist, within the practitioner’s scope of practice. (3) Requires a written referral by a physician or dentist, within the practitioner’s scope of practice. (4) Requires a recommendation by a physician, registered credentialed school nurse, licensed clinical social worker, licensed psychologist, licensed educational psychologist, or licensed marriage and family therapist, within the practitioner’s scope of practice. (5) Licensed registered nurses and certified nurse practitioners who do not have valid credentials require supervision. (6) Certified public health nurses who do not have valid credentials require supervision, except when providing specialized physical health care services as specified in California Education Code, Section 49423.5.

General Notes: MEDICAL TRANSPORTATION AND MILEAGE ALSO ARE REIMBURSABLE TO LEAs PURSUANT TO STANDARDS IN CALIFORNIA CODE OF REGULATIONS (CCR), TITLE 22, SECTION 51491(h). Credentialing requirements for licensed practitioners employed by LEAs are described in the Local Educational Agency (LEA) Rendering Practitioner Qualifications section of this manual.

loc ed bil 8

2 – Local Educational Agency (LEA) Outpatient Services – LEA 382 Billing and Reimbursement Overview August 2006

Service Limitations LEAs are authorized to bill for the services as outlined in the preceding charts for students with or without an Individualized Education Plan (IEP) or Individualized Family Services Plan (IFSP). LEA providers must use the appropriate billing CPT-4 or HCPCS code based on the student’s plan of care or assessment needs.

Service limitations vary depending on the type of service received.

Service limitations specific to each service type are included in the various Local Educational Agency (LEA) Services sections of this manual. For example, service limitations related to physical therapy treatments are located in the Local Educational Agency (LEA) Service: Physical Therapy section.

LEA services not authorized in a student’s IEP or IFSP are limited to a

maximum of 24 services (assessment, treatment and transportation) per 12-month period for a recipient without prior authorization. For non-IDEA (Individuals with Disabilities Education Act) students, LEAs may obtain prior authorization for LEA services rendered beyond 24 services per 12-month period from:

• California Children’s Services program

• Short-Doyle program

• Medi-Cal Field Office (Treatment Authorization Request)

• Prepaid health plan (including Primary Care Case Management)

IEP/IFSP Assessments The number of IEP and IFSP assessments that providers may perform

is limited by service type. Information about the limits, and additional IEP and IFSP information is located in the Local Educational Agency (LEA): Individualized Plans section of this manual.

loc ed bil 9


Initial and Additional Information about initial and additional treatment services is located Treatment Services in the following sections:

• Local Educational Agency (LEA) Service: Hearing • Local Educational Agency (LEA) Service: Occupational

Therapy • Local Educational Agency (LEA) Service: Physical Therapy • Local Educational Agency (LEA) Service: Physician Billable

Procedures • Local Educational Agency (LEA) Service: Psychology/

Counseling • Local Educational Agency (LEA) Service: Speech Therapy

Treatment Services Information about treatment services billed solely in 15-minute Billed in 15-Minute increments (with no initial or additional treatment services) is located Increments in the following sections:

• Local Educational Agency (LEA) Service: Nursing • Local Educational Agency (LEA) Service: Targeted Case

Management Medical Transportation Information about medical transportation and mileage is located and Mileage in the Local Educational Agency (LEA) Service: Transportation

(Medical) section.

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Modifiers Modifiers are codes added on a claim line with the procedure code to indicate that the procedure was altered by some specific circumstance, but not changed in its definition or code. For LEA billing purposes, the interpretation of some modifiers may differ slightly from the national description. An overview of the variety of modifiers that may be submitted on LEA claims follows. (Only select procedure codes and circumstances require modifiers.)

Note: To help providers bill for services, the “Billing Codes and

Services Limitations” charts in each of the Local Educational Agency (LEA) Service sections provide a guideline for the modifier(s) that must be submitted with each procedure code.

Individualized Plan Modifiers The modifiers below allow accurate processing and enable the

approval of additional LEA services beyond 24 services per 12-month period. (Information about service limitations is located under the heading “Service Limitations” in this section.)

National Modifier Modifier Description LEA Program Usage

TL Early Intervention/ Service is part of an Individualized Family IFSP Services Plan (IFSP)

TM Individualized Service is part of an Education Program Individualized Education

Plan (IEP) Modifiers TL and TM also must be used to indicate LEA services

rendered to a student who is a member of a Medi-Cal managed care plan or who is receiving TCM services and the services are authorized in the student’s IEP or IFSP.

loc ed bil 11


Practitioner Modifiers A practitioner modifier identifies the type of practitioner who rendered a service. Modifiers used for the LEA Program are broadly interpreted in some cases.


AG Primary physician Licensed physicians/psychiatrists

AH Clinical psychologist Licensed psychologists, licensed educational psychologists and credentialed school psychologists

AJ Clinical social worker Licensed clinical social

workers and credentialed social workers

GN Service delivered Licensed speech-language

under an outpatient pathologists and speech- speech-language language pathologists

pathology plan of care GO Service delivered Registered occupational

under an outpatient therapists occupational therapy plan of care

GP Service delivered Licensed physical therapists under an outpatient physical therapy plan of care HO Masters degree level Program specialists TD RN Registered credentialed

school nurses, registered credentialed school nurses

(who are also registered school audiometrists), licensed registered nurses, certified public health nurses and certified nurse practitioners

TE LPN/LVN Licensed vocational

nurses

loc ed bil 12


Intensity of Service Modifiers Intensity of service modifiers are national modifiers used to identify the type of service rendered, and include the following:


22 Increased procedural Additional 15-minute services service increment rendered

beyond the required initial service time

52 Reduced services Annual re-assessment

TS Follow-up service Amended re-assessment Computer Media Computer Media Claim (CMC) submission is the most efficient Claims (CMC) method of submitting Medi-Cal claims. CMCs are submitted via

asynchronous telecommunications (modem) or on the Medi-Cal Web site at www.medi-cal.ca.gov. CMC submission bypasses the claims preparation and data entry processes of hard copy claims and goes directly into the claims processing system. CMC submission offers additional efficiency to providers because these claims are submitted faster, entered into the claims processing system faster and paid faster.

CMC submissions require a computerized claims billing system. LEA

providers may prepare the CMC submission themselves or contract with a DHCS-approved billing service to prepare and submit their claims. Generally, the claim submission requirements of CMC are the same as for paper claims. Because CMC submission is a “paperless” billing process, there are some special requirements. Additional information is available in the CMC section of the Part 1 Medi-Cal provider manual.

loc ed bil 13


Claim Submission: LEA services can be billed on a paper UB-04 claim. Instructions UB-04 Claim for preparing and submitting the claim are included in the UB-04

Completion: Outpatient Services section of this manual. Explanation of UB-04 Items specific to LEA should be completed as follows: Form Items

Type of Bill (Box 4). Enter the facility type code “89” in the first two spaces of this field. Provider Name, Address, ZIP Code (Box 1). Enter the official name of the LEA (for example, school district or county office of education), address and the nine-digit ZIP code in the space provided at the upper left hand corner of the UB-04 claim. HCPCS/Rates (Box 44). Enter the applicable HCPCS/CPT-4 code(s). Add modifier(s) if required. Additional information about reimbursable codes and required modifiers is included in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual. Total Charges (Box 47). Enter the usual and customary charges. Additional information about rates is in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual. Payer (Box 50). Enter the words “O/P MEDI-CAL” in Box 50 to indicate the type of claim and payer. List the name of the school district in the Remarks field (Box 80). Operating NPI (Box 77). Enter the NPI of the medical professional actually providing the service. For LEA, the independent contractor is defined as a medical professional that is not a direct employee of the LEA and provides health care services to students. Note: LEAs billing for services rendered by their own employees who do not have individual NPI numbers should leave the Operating NPI field blank. LEA employees are paid a salary by the LEA

(for example, the district or county office of education).

loc ed bil 14


ICD-9-CM Codes ICD-9-CM diagnosis codes are identified in the International Classification of Diseases, 9th Revision, Clinical Modification

(ICD-9-CM) code book that was developed to create international uniformity in diagnosing health conditions. Current copies of the ICD-9-CM code book are available by writing or calling:

Ingenix P.O. Box 27116 Salt Lake City, UT 84127-0116 Telephone: 1-800-INGENIX (464-3649)

Or

PMIC (Practice Management Information Corporation) Order Processing Department 4727 Wilshire Boulevard, Suite 300 Los Angeles, CA 90010-3894 Telephone: 1-800-MED-SHOP (633-7467) (Monday – Friday, 8:00 a.m. – 5:30 p.m., CST) Fax: 1-800-633-6556 (24 hours daily) (For credit card orders or purchase orders)

Note: ICD-9-CM codes must be included on the claim or the claim

will be denied. Billing instructions are included in the UB-04 Completion: Outpatient Services section of this manual.

loc ed bil 15


“From-Through” Billing All LEA services except mileage (associated with medical transportation) may be billed on a “from-though” basis when the same service(s) are rendered more than once in a month. This is to facilitate billing when there is more than one date of service.

Consecutive and “From-through” billing may be used for both consecutive and Non-Consecutive Days non-consecutive days of service. Claim Completion Two claim lines are completed when billing the “from-through” Instructions format.

• Line 1: Enter the service description in the Description field (Box 43) and the initial date on which the procedure was rendered in the Service Date field (Box 45).

• Line 2: Indicate the individual dates of service in the Description field (Box 43), the procedure code in the HCPCS/Rate field (Box 44) and the last date of treatment in the Service Date field (Box 45). Enter the total number of units provided in the Service Units field (Box 46). Enter the total amount in the Total Charges field (Box 47).

See Figure 4 in the Local Educational Agency (LEA) Billing Examples section in this manual for a “from-though” billing example.

Claim Submission and LEA claims must be received by the DHCS Fiscal Intermediary (FI) Twelve-Month Billing Limit within 12 months following the month in which services were rendered. Claims are submitted to the following address:


Retroactive Billing From LEA services are reimbursable within 12 months of the month of Date of Service service, as long as the claim is billed within statutory limits. LEAs,

therefore, are not subject to the six-month billing guidelines. Figure 5 in the Local Educational Agency (LEA) Billing Examples section of this manual illustrates a retroactive billing example.

loc ed bil 16


Retroactive Billing From Providers enter their Targeted Case Management (TCM) certification TCM Date of Certification date in the Remarks field (Box 80) when billing for TCM services rendered between their certification date and up to a maximum of

12 months retroactively. (LEAs receive a notice from the Medi-Cal DHCS Safety Net Financing Division that contains their certification date and county LEA TCM reimbursement rate). Billing Reminders When billing, providers should remember:

• Only bill for one student per claim form.

• In the HCPCS/Rate field (Box 44) enter the modifier TL (IFSP) or TM (IEP), if applicable, to indicate that the LEA service is authorized in the student’s IEP or IFSP. The use of these modifiers indicates the approval of additional LEA services beyond the 24 LEA services per 12-month period limitation.

• In the HCPCS/Rate field (Box 44) enter the practitioner modifier, if applicable, to designate the practitioner who rendered the specific LEA service to the student. Practitioner modifier information for each LEA service is in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual.

• Enter the first and second modifiers in the HCPCS/Rate field (Box 44) on the claim, if applicable.

If the same procedure code and modifier combination (assessment, treatment, transportation or TCM) is billed on more than one line of a claim or on different claim forms for the same date of service, it will appear that the procedure was billed twice in error. To avoid duplicate billing, providers should complete one claim for multiple sessions, entering the number of sessions in the Service Units field (Box 46) and the time of each session in the Remarks field (Box 80). Figure 2 in the Local Educational Agency (LEA) Billing Examples section of this manual illustrates billing more than one session on the same date of service.

Local Educational Agency (LEA) loc ed bil cd Billing Codes and Reimbursement Rates 1

2 – Local Educational Agency (LEA) Outpatient Services – LEA 443 Billing Codes and Reimbursement Rates August 2011

This section contains a list of procedure codes that are reimbursable in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program. Maximum allowable rates and the types of qualified rendering practitioners who may perform the services are detailed in this section. Reimbursement Rates The Federal Medical Assistance Percentage (FMAP) reimbursable for

LEA services is applied to the Medi-Cal maximum allowable rates listed in the LEA Services Billing Codes Chart in this section. Medi-Cal LEA reimbursement rates fluctuate in tandem with

adjustments to the FMAP, per federal financial participation (FFP) regulations. LEA Services Billing The “LEA Services Billing Codes Chart” is a quick reference guide Codes Chart to each LEA service. The chart identifies the following:

• LEA-reimbursable CPT-4 and HCPCS codes (with descriptors) • Modifiers • Service time requirements for “initial” and “additional” services • Qualified practitioners • Medi-Cal maximum allowable rates

The chart divides information into four categories:

• IEP/IFSP assessments • Non-IEP/IFSP assessments • Treatments and transportation • Targeted Case Management

LEA Services Billing Codes Chart (effective July 1, 2010)

IEP/IFSP Assessments

Procedure Code/ Modifier

LEA Program Usage

Service Description

Qualified Practitioner (Practitioner Modifier)

Maximum Allowable

Rate

Physical Therapy Assessment

97001 TL (IFSP) or

97001 TM (IEP)

Initial or triennial IEP/IFSP

physical therapy assessment

Physical therapy evaluation

Licensed physical therapist (no modifier)

$240.31

97002 TL (IFSP) or

97002 TM (IEP)

Amended IEP/IFSP physical therapy

assessment

Physical therapy re-evaluation

Same as preceding $166.88

97001 52 TL (IFSP)

or 97001 52 TM

(IEP)

Annual IEP/IFSP physical therapy

assessment

Reduced services Same as preceding $166.88

loc ed bil cd 2




LEA Program Usage

Service Description


Maximum Allowable

Rate

Occupational Therapy Assessment

97003 TL (IFSP) or

97003 TM (IEP)


occupational therapy

assessment

Occupational therapy evaluation

Registered occupational therapist

(no modifier)

$222.91

97004 TL (IFSP) or

97004 TM (IEP)

Amended IEP/IFSP occupational

therapy assessment

Occupational therapy re-evaluation


97003 52 TL (IFSP)

or 97003 52 TM

(IEP)

Annual IEP/IFSP occupational

therapy assessment


Speech-Language Assessment

92506 TL (IFSP) or

92506 TM (IEP)


speech-language assessment

Evaluation of speech, language, voice, communication,

auditory processing and/or aural

rehabilitation status

Licensed speech-language pathologist (GN)

Speech-language pathologist (GN)

$208.67

92506 TS TL (IFSP)

or 92506 TS TM

(IEP)

Amended IEP/IFSP speech-language

assessment

Follow-up service Same as preceding $113.82

92506 52 TL (IFSP)

or 92506 52 TM

(IEP)

Annual IEP/IFSP speech-language

assessment


loc ed bil cd 3




LEA Program Usage

Service Description


Maximum Allowable

Rate

Audiological Assessment

92506 TL (IFSP) or

92506 TM (IEP)


audiological assessment

Evaluation of speech, language, voice, communication,

auditory processing and/or aural

rehabilitation status

Licensed audiologist (no modifier)

Audiologist (no modifier)

$168.82

92506 TS TL (IFSP) or

92506 TS TM (IEP)

Amended IEP/IFSP audiological assessment


92506 52 TL (IFSP) or

92506 52 TM (IEP)

Annual IEP/IFSP audiological assessment


Psychological Assessment

96101 TL (IFSP) or

96101 TM (IEP)


psychological assessment

Psychological testing (includes

psychodiagnostic assessment of emotionality,

intellectual abilities, personality and

psychopathology, eg. MMPI, Rorshach,

WAIS)

Licensed psychologist (no modifier)

Licensed educational psychologist (no modifier)

Credentialed school psychologist (no modifier)

$455.70


96101 TS TM (IEP)

Amended IEP/IFSP psychological assessment


96101 52 TL (IFSP) or

96101 52 TM (IEP)

Annual IEP/IFSP psychological assessment


loc ed bil cd 4




LEA Program Usage

Service Description


Maximum Allowable

Rate

Psychosocial Status Assessment

96150 TL (IFSP) or

96150 TM (IEP)


psychosocial status

assessment, each completed 15-minute increment

Initial health and behavior assessment

(for example, health-focused clinical interview, behavioral

observations, psycho-physiological

monitoring, health-oriented

questionnaires), each 15 minutes

face-to-face with the patient

Licensed clinical social worker (AJ)

Credentialed school social worker (AJ)

Licensed marriage and family therapist (no modifier)

Credentialed school counselor

(no modifier)

$16.66

96151 TL (IFSP) or

96151 TM (IEP)

Amended IEP/IFSP

psychosocial status


Health and behavior re-assessment (for example,

health-focused clinical interview, behavioral






96150 52 TL (IFSP)

or 96150 52 TM

(IEP)

Annual IEP/IFSP psychosocial

status assessment, each

completed 15-minute increment

Reduced services, each 15 minutes



loc ed bil cd 5




LEA Program Usage

Service Description


Maximum Allowable

Rate

Health Assessment

T1001 TL (IFSP) or

T1001 TM (IEP)


health assessment

Nursing assessment/ evaluation

Registered credentialed school nurse (no modifier)

$127.91

T1001 TS TL (IFSP)

or T1001 TS TM

(IEP)

Amended IEP/IFSP

health assessment


T1001 52 TL (IFSP) or

T1001 52 TM (IEP)

Annual IEP/IFSP health assessment


loc ed bil cd 6




LEA Program Usage

Service Description


Maximum Allowable

Rate

Health/Nutrition Assessment

96150 TL (IFSP) or

96150 TM (IEP)


health/nutrition assessment, each


Initial health and behavior assessment

(for example, health-focused clinical interview, behavioral





Licensed physician/psychiatrist

(AG)

$18.27

96151 TL (IFSP) or

96151 TM (IEP)

Amended IEP/IFSP

health/nutrition assessment, each









96150 52 TL (IFSP)

or 96150 52 TM

(IEP)

Annual IEP/IFSP health/nutrition


Reduced services, each 15 minutes



loc ed bil cd 7


Non-IEP/IFSP Assessments


LEA Program Usage

Service Description


Maximum Allowable

Rate

Psychosocial Status Assessment

96150 Psychosocial status assessment, each


Initial health and behavior

assessment (for example,






Licensed psychologist (AH)

Licensed educational psychologist (AH)

Credentialed school psychologist (AH)





(no modifier)

$18.99

96151 Psychosocial status re-assessment, each completed

15-minute increment








loc ed bil cd 8




LEA Program Usage

Service Description


Maximum Allowable

Rate

Developmental Assessment

96110 Developmental assessment, each


(applicable to initial assessment and re-assessment)

Developmental testing; limited (for example,

Developmental Screening Test II, Early Language

Milestone Screen), with interpretation and

report

Licensed physical therapist (GP)

Registered occupational therapist (GO)

Licensed speech-language pathologist

(GN)


GP: $20.86

GO: $19.35

GN: $18.97

Health Education/Anticipatory Guidance

99401 Health education/ anticipatory

guidance, each completed 15-minute increment

(applicable to initial assessment and re-assessment)

Preventive medicine counseling and/or risk

factor reduction intervention(s) provided to an

individual (separate procedure);

approximately 15 minutes


(AG)

Registered credentialed school nurse (TD)



Credentialed school psychologist (AH)





(no modifier)

AG or TD:

$18.27

AH, AJ or

marriage family

therapist/ school

counselor: $18.99

loc ed bil cd 9




LEA Program Usage

Service Description


Maximum Allowable

Rate

Health/Nutrition Assessment

96150 Health/nutrition assessment, each


Initial health and behavior

assessment (for example,







(AG)


$18.27

96151 Health/nutrition re-assessment, each completed

15-minute increment








Vision Assessment

99173 Vision assessment Screening test of visual acuity,

quantitative bilateral


(AG)


Licensed optometrist (no modifier)

$6.09

loc ed bil cd 10

2 – Local Educational Agency (LEA) Outpatient Services – LEA 428 Billing Codes and Reimbursement Rates May 2010



LEA Program Usage

Service Description


Maximum Allowable

Rate

Hearing Assessment

92551 Hearing assessment

Screening test, pure tone, air only


(AG)

Licensed speech-language

pathologist (GN)




Registered school audiometrist (no modifier)

Registered credentialed school nurse (registered

school audiometrist) (TD)

$14.26 (younger than 18)

$13.07 (18 and older)

92552 Hearing assessment

Pure tone audiometry (threshold); air only

Same as preceding $21.38 (younger than 18)

$19.60 (18 and older)

loc ed bil cd 11


Treatments and Transportation


LEA Program Usage

Service Description


Maximum Allowable

Rate

Physical Therapy

97110 TL (IFSP) or

97110 TM (IEP) or

97110 (non-IEP/IFSP)

Therapeutic procedure, one or more areas, each

15 minutes; therapeutic exercises to

develop strength and endurance, range of motion

and flexibility (maximum of 3 units per initial

service)

Therapeutic procedure, one or

more areas, each 15 minutes; therapeutic exercises to develop

strength and endurance, range of motion and flexibility (maximum of 3 units

per initial service)

Licensed physical therapist (GP)

$66.75

97110 22 TL (IFSP)

or 97110 22 TM

(IEP) or

97110 22 (non-IEP/IFSP)

Unusual procedural services



Occupational Therapy

97110 TL (IFSP) or

97110 TM (IEP) or


Therapeutic procedure, one or more areas, each

15 minutes; therapeutic exercises to

develop strength and endurance, range of motion

and flexibility (maximum of 3 units per initial

service)

Therapeutic procedure, one or

more areas, each 15 minutes; therapeutic exercises to develop

strength and endurance, range of motion and flexibility (maximum of 3 units


Registered occupational therapist (GO)

$73.53

97110 22 TL (IFSP)

or 97110 22 TM

(IEP) or





loc ed bil cd 12




LEA Program Usage

Service Description


Maximum Allowable

Rate

Speech Therapy

92507 TL (IFSP) or

92507 TM (IEP) or


Speech therapy initial service,

15 – 45 continuous minutes, individual

(bill 1 unit per 15-minute increment)

Treatment of speech, language, voice, communication, and/or auditory

processing disorder (includes aural rehabilitation);

individual (maximum of 3 units per initial

service)

Licensed speech-language pathologist (GN)


$63.23

92507 22 TL (IFSP)

or 92507 22 TM

(IEP) or


Speech therapy service, additional

15-minute increment, individual



92508 TL (IFSP) or

92508 TM (IEP) or


Speech therapy initial service,

15 – 45 continuous minutes, group (bill 1 unit per

15-minute increment)

Treatment of speech, language, voice, communication, and/or auditory

processing disorder (includes aural

rehabilitation); group, two or more

individuals (maximum of 3 units per initial

service)


92508 22 TL (IFSP)

or 92508 22 TM

(IEP) or



15-minute increment, group



loc ed bil cd 13




LEA Program Usage

Service Description


Maximum Allowable

Rate

Audiology

92507 TL (IFSP) or

92507 TM (IEP) or


Audiology initial service

15 – 45 continuous minutes, individual


Treatment of speech, language, voice,

communication and/or auditory processing disorder (includes

aural rehabilitation); individual (maximum of 3 units per initial

service)



$77.38

92507 22 TL (IFSP)

or 92507 22 TM

(IEP) or


Audiology service, additional 15-minute increment, individual



V5011 TL (IFSP) or

V5011 TM (IEP)

Hearing check Fitting/orientation/ checking of hearing aid


loc ed bil cd 14




LEA Program Usage

Service Description


Maximum Allowable

Rate

Psychology and Counseling

96152 TL (IFSP) or

96152 TM (IEP) or


Psychology/ counseling initial service, 15 – 45

continuous minutes, individual


Health and behavior intervention, each 15

minutes, face-to-face; individual (maximum of 3 units



(AG) Licensed psychologist

(AH) Licensed educational

psychologist (AH) Credentialed school psychologist (AH)




$69.92

96152 22 TL (IFSP)

or 96152 22 TM

(IEP) or


Psychology/ counseling, additional 15-minute increment, individual



96153 TL (IFSP) or

96153 TM (IEP) or



continuous minutes, group (bill

1 unit per 15-minute increment)

Health and behavior intervention, each 15

minutes, face-to-face; group, two or more patients (maximum of 3 units



96153 22 TL (IFSP) or

96153 22 TM (IEP)

or 96153 22

(non-IEP/IFSP)

Psychology/ counseling, additional 15-minute

increment, group



loc ed bil cd 15




LEA Program Usage

Service Description


Maximum Allowable

Rate

Nursing and School Health Aide Services

T1002 TL (IFSP) or

T1002 TM (IEP) or

T1002 (non-IEP/IFSP)

Nursing services, RN, 15-minute

increment

RN services, up to 15 minutes

Registered credentialed school nurse (no modifier)

Licensed registered nurse (no modifier)

Certified public health nurse

(no modifier)

Certified nurse practitioner (no modifier)

$18.27

T1003 TL (IFSP) or

T1003 TM (IEP) or


Nursing services, LVN, 15-minute

increment

LPN/LVN services, up to 15 minutes

Licensed vocational nurse (no modifier)

$9.22

T1004 TL (IFSP) or

T1004 TM (IEP) or


School health aide services, 15-minute increment

Qualified nursing aide services, up to 15

minutes

Trained health care aide (no modifier)

$7.77

Medical Transportation

T2003 TL (IFSP) or

T2003 TM (IEP) or


Medical transportation,

per one-way trip, wheelchair van or

litter van

Non-emergency transportation; encounter/trip

$18.54

A0425 TL (IFSP) or

A0425 TM (IEP) or

A0425 (non-IEP/IFSP)

Mileage Ground mileage, per statute mile

$1.30

loc ed bil cd 16

2 – Local Educational Agency (LEA) Outpatient Services – LEA 388 Billing Codes and Reimbursement Rates February 2007

Targeted Case Management


LEA Program Usage

Service Description


Maximum Allowable

Rate


T1017 TL (IFSP) or

T1017 TM (IEP)

Targeted case management,

15-minute increment

Targeted case management, each 15

minutes


Licensed registered nurse (TD)

Certified public health nurse (TD)

Certified nurse practitioner (TD)





Credentialed school psychologist

(AH)



(no modifier)

Licensed vocational nurse (TE)

Program specialist (HO)

Low cost provider: $12.38

Medium cost

provider: $14.40

High cost provider: $16.42

loc ed bil ex Local Educational Agency (LEA) Billing Examples 1

2 – Local Educational Agency (LEA) Billing Examples Outpatient Services – LEA 391 May 2007

Examples in this section are to help providers bill Local Educational Agency (LEA) services on the UB-04 claim form. Refer to the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual for detailed policy information. Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete claim fields not explained in the following example(s). For additional claim preparation information, refer to the Forms: Legibility and Completion Standards section of this manual. Billing Tips: When completing claims, do not enter the decimal points in ICD-9-CM codes or dollar

amounts. If requested information does not fit neatly in the Remarks field (Box 80) of the claim, type it on an 8½ x 11-inch sheet of paper and attach it to the claim.

loc ed bil ex 2

2 – Local Educational Agency (LEA) Billing Examples Outpatient Services – LEA 443 August 2011

One Session Figure 1. One session developmental assessment rendered to a Developmental Assessment, student whose care is not subject to an Individualized Education Non-IEP/IFSP Student Plan (IEP) or Individualized Family Services Plan (IFSP).

This is a sample only. Please adapt to your billing situation. In this case, a licensed physical therapist renders a developmental assessment to a non-IEP/IFSP student on July 5, 2010. The session lasts 45 minutes. Enter the two-digit facility type code “89” (special facility – other) and one-character claim frequency code “1” as “891” in the Type of Bill field (Box 4). CPT-4 code 96110 (developmental assessment) with modifier GP (physical therapist) is entered on claim line 1 in the HCPCS/Rate field (Box 44). An explanation of code 96110 is placed in the Description field (Box 43). The date of service for the assessment is placed in the Service Date field (Box 45) in six-digit format (070510). A 3 is entered in the Service Units field (Box 46) for code 96110 to bill for the 45-minute session. (Code 96110 is billed in 15-minute increments (45 ÷ 15 = 3.) Enter the usual and customary charges in the Total Charges field (Box 47). Enter code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in the Totals field (Box 47, line 23). Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete the Payer Name field (Box 50) and the Insured’s Unique ID field (Box 60). The LEA provider’s National Provider Identifier (NPI) is placed in the NPI field (Box 56). An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this case, ICD-9-CM code V57.1 represents other physical therapy and is entered on the claim as V571. Enter the NPI of the medical professional actually rendering the service in the Operating field (Box 77). For LEA, the independent contractor is defined as a medical professional who is not a direct employee of the LEA and provides health care services to students. (For information about LEAs billing for services rendered by their own employees who do not have individual NPIs, refer to “Claim Submission: UB-04 Claim Form” in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.) The name of the school district is required in the Remarks field (Box 80).

loc ed bil ex 3


Figure 1. One Session Developmental Assessment, Non-IEP/IFSP Student.

loc ed bil ex 4


Two Sessions of Figure 2. Two speech therapy treatment sessions on the same Speech Therapy on date of service, IEP student. Same Date of Service, IEP Student This is a sample only. Please adapt to your billing situation.

In this case, a licensed speech-language pathologist provides two individual speech therapy sessions to a student with an IEP on July 15, 2010. The morning session lasts 60 minutes and the afternoon session lasts 55 minutes. Enter the two-digit facility type code “89” (special facility – other) and one-character claim frequency code “1” as “891” in the Type of Bill field (Box 4). CPT-4 code 92507 (speech therapy initial service, individual) is entered with modifiers GN (licensed speech-language pathologist) and TM (IEP) on claim line 1 in the HCPCS/Rate field (Box 44). The additional speech therapy session is billed on claim line 2 with CPT-4 code 92507 and modifiers 22 (additional 15-minute service), GN and TM. Explanations for both 92507 services are placed in the Description field (Box 43) and a date of service for each session is placed in the Service Date field (Box 45) in six-digit format (071510). A 3 is entered in the Service Units field (Box 46) on claim line 1 for the initial service. Though the session lasted for 60 minutes (four 15-minute units), reimbursement for the initial service is limited to 3 units. A 5 is entered in the Service Units field on claim line 2 for the additional services provided beyond the initial service. The 5 represents the additional 15-minute increment from the morning session, 3 standard 15-minute units in the afternoon and a “rounding up” of the remaining 10 minutes. (For billing purposes, a continuous treatment session of seven or more minutes qualifies to be billed as a unit.) Enter the usual and customary charges in the Total Charges field (Box 47). Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in the Totals field (Box 47, line 23). Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete the Payer Name field (Box 50) and the Insured’s Unique ID field (Box 60). The LEA provider’s NPI is placed in the NPI field (Box 56).

loc ed bil ex 5


An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this case, ICD-9-CM code 307.9 represents lisping and is entered on the claim as 3079. Enter the NPI of the medical professional actually rendering the service in the Operating field (Box 77). For LEA, the independent contractor is defined as a medical professional who is not a direct employee of the LEA and provides health care services to students. (For information about LEAs billing for services rendered by their own employees who do not have individual NPIs, refer to “Claim Submission: UB-04 Claim Form” in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.) The name of the school district and time of day for each speech therapy session is required in the Remarks field (Box 80).

loc ed bil ex 6


Figure 2. Two Sessions of Speech Therapy on Same Date of Service, IEP Student.

loc ed bil ex 7


One Session Figure 3: One session, initial health assessment, IEP student. Initial Health Assessment, IEP Student This is a sample only. Please adapt to your billing situation.

In this case a registered credentialed school nurse provides an initial health assessment to a student with an IEP on July 20, 2010. Enter the two-digit facility type code “89” (special facility – other) and one character claim frequency code “1” as “891” in the Type of Bill field (Box 4). On claim line 1, HCPCS code T1001 (initial or triennial IEP health assessment) is entered with modifier TM (IEP) in the HCPCS/Rate field (Box 44). An explanation of code T1001 is placed in the Description field (Box 43). The date of service is placed in the Service Date field (Box 45) in six-digit format (072010). Enter a “1” in the Service Units field (Box 46) for code T1001 and the usual and customary charges in the Total Charges field (Box 47). Enter code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in the Totals field (Box 47, line 23). Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete the Payer Name field (Box 50) and the Insured’s Unique ID field (Box 60). The LEA provider’s NPI is placed in the NPI field (Box 56). An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this case, ICD-9-CM code 307.50 represents an unspecified eating disorder and is entered on the claim as 30750. Enter the NPI of the medical professional actually rendering the service in the Operating field (Box 77). For LEA, the independent contractor is defined as a medical professional who is not a direct employee of the LEA and provides health care services to students. (For information about LEAs billing for services rendered by their own employees who do not have individual NPIs, refer to “Claim Submission: UB-04 Claim Form” in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.) The name of the school district is required in the Remarks field (Box 80).

loc ed bil ex 8


Figure 3. One Session, Initial Health Assessment, IEP Student.

loc ed bil ex 9


“From-Through” Billing: Figure 4. “From-through” billing: Two or more sessions on different Two or More Sessions dates of service, IEP student. On Different Dates of Service, IEP Student This is a sample only. Please adapt to your billing situation.

In this case, a licensed speech-language pathologist provides individual speech therapy sessions to a student with an IEP for seven days, starting on July 12, 2010. Each session is 20 minutes. Enter the two-digit facility type code “89” (special facility – other) and one-character claim frequency code “1” as “891” in the Type of Bill field (Box 4). On claim line 1 enter an explanation of code 92507 (speech therapy initial service, individual) in the Description field (Box 43). Enter the beginning date of service (July 12, 2010) in six-digit format in the Service Date field (Box 45) as 071210. No other information is entered on this line. On claim line 2, enter CPT-4 code 92507 with modifiers GN (licensed speech-language pathologist) and TM (IEP) in the HCPCS/Rate field (Box 44). Enter the specific dates the services were rendered (7/12, 13, 14, 15, 16, 19 and 20) in the Description field (Box 43). The “through,” or last, date of service (July 20, 2010) is entered in the Service Date field (Box 45) as 072010. Note: “From-through” billing may be used for both consecutive and

non-consecutive dates of service. Enter a 7 in the Service Units field (Box 46) on claim line 2 to indicate the number of days the student received the initial speech therapy services. Enter the usual and customary charges in the Total Charges field (Box 47). Enter code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in the Totals field (Box 47, line 23). Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete the Payer Name field (Box 50) and the Insured’s Unique ID field (Box 60). The LEA provider’s NPI is placed in the NPI field (Box 56). An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this case, ICD-9-CM code 307.9 represents lisping and is entered on the claim as 3079.

loc ed bil ex 10

2 – Local Educational Agency (LEA) Billing Examples Outpatient Services – LEA 391 May 2007

Enter the NPI of the medical professional actually rendering the service in the Operating field (Box 77). For LEA, the independent contractor is defined as a medical professional who is not a direct employee of the LEA and provides health care services to students. (For information about LEAs billing for services rendered by their own employees who do not have individual NPIs, refer to “Claim Submission: UB-04 Claim Form” in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.) The name of the school district is required in the Remarks field (Box 80).

loc ed bil ex 11


Figure 4. “From-Through” Billing: Two or More Sessions on Different Dates of Service, IEP Student.

loc ed bil ex 12


Retroactive Billing: Figure 5. Retroactive billing, IEP student. IEP Student

This is a sample only. Please adapt to your billing situation. In this case, three LEA services were rendered in April 2010 to a student with an IEP, 12 months before proof of the student’s eligibility could be established. When eligibility was confirmed in April 2011, the LEA provider billed retroactively. Enter the two-digit facility type code “89” (special facility – other) and one character claim frequency code “1” as “891” in the Type of Bill field (Box 4). CPT-4 code 96101, HCPCS code T1004 and CPT-4 code 96152 are billed on subsequent claim lines in the HCPCS/Rate field (Box 44) for the three services rendered (initial psychological assessment, school health aide services and initial psychology/counseling services). An explanation of each of the services is placed in the Description field (Box 43). In addition, the appropriate modifiers are placed next to each procedure code, including the TM modifier to denote the services were performed under an IEP, and modifier AJ next to procedure code 96152 to indicate the initial psychology/counseling service was rendered by a credentialed school social worker. The date each service was rendered is placed in the Service Date field (Box 45) in six-digit format (041610, 042610 and 042910). Enter a 1 in the Service Units field (Box 46) for the initial assessment and counseling service (codes 96101 and 96152) and a 3 in the Service Units field for the school health aide services. The 3 represents the 45 minutes that the trained health care aide spent with the student. School health aide services are billed in 15-minute increments (45 ÷ 15 = 3). Enter the usual and customary charges in the Total Charges field (Box 47). Enter code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in the Totals field (Box 74, line 23). Refer to the UB-04 Completion: Outpatient Services section of this manual for instructions to complete the Payer Name field (Box 50) and the Insured’s Unique ID field (Box 60). The LEA provider’s NPI is placed in the NPI field (Box 56).

loc ed bil ex 13

2 – Local Educational Agency (LEA) Billing Examples Outpatient Services – LEA 398 November 2007

An appropriate ICD-9-CM diagnosis code is entered in Box 67. In this case, ICD-9-CM code V18.4 represents mental retardation and is entered on the claim as V184. No NPI is required in the Operating field (Box 77) because the service was rendered by an employee of the LEA and the employee does not have an individual NPI. (For information about LEAs billing for services rendered by their own employees who do not have individual NPIs, refer to “Claim Submission: UB-04 Claim Form” in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.) All LEA claims require the name of the school district in the Remarks field (Box 80). In addition, because the provider is submitting a retroactive claim, the claim includes clarification in the Remarks field of the date that proof of recipient eligibility was established (month, day and year).

loc ed bil ex 14


Figure 5. Retroactive Billing, IEP Student.

Local Educational Agency (LEA) loc ed elig Eligible Students 1

2 – Local Educational Agency (LEA) Eligible Students Outpatient Services – LEA 391 May 2007

This section contains information to help Local Educational Agencies (LEAs) determine Medi-Cal recipient eligibility for students and family members who may receive services under the Local Educational Agency Medi-Cal Billing Option Program. Eligible Students To participate in the LEA Program, students must be certified as

eligible for Medi-Cal for the dates that services are rendered. LEAs will not receive reimbursement under the Medi-Cal LEA Billing Option when the student is only eligible for the following services:

• Programs solely funded by the State

• Minor Consent Program

Some students may also be required to meet a Share of Cost before being certified as eligible for Medi-Cal services. Refer to the Share of Cost (SOC) section in the Part 1 Medi-Cal provider manual and the Share of Cost (SOC): UB-04 for Outpatient Services section in this manual.

Ineligible Aid Codes Students with the following aid codes are ineligible for Medi-Cal

reimbursable LEA services:

01 44 53 7G 71 81 02 48 55 7H 73 84 07 5F 58 7K 74 85 08 5T 6U 7M 75 88 1H 5W 65 7N 79 1U 5X 69 7P 8F 3T 5Y 7C 7R 8N 3V 50 7F 70 8T

Descriptions for these aid codes are in the Aid Codes Master Chart in

the Part 1 Medi-Cal provider manual.

loc ed elig 2

2 – Local Educational Agency (LEA) Eligible Students Outpatient Services – LEA 397 October 2007

Determining Eligibility To determine a student’s eligibility, providers may use one of the following options:

• For a one-year retroactive period, beginning with the date of enrollment, and then on a quarterly basis, LEAs may obtain eligibility verification information by sending data in a specific format via the Internet. This is a unique process created by the Department of Health Care Services (DHCS) specifically for LEAs. Information about this process is available to LEAs from DHCS Information Technology Services Division (ITSD). (Contact information for ITSD is available in the Local Educational Agency (LEA) section of this manual.) ITSD representatives provide LEAs with data layout formats and specific information to perform the process.

• Memorandum of Understanding (MOU): LEAs may enter into an agreement with their county welfare department to process the eligibility files for their service population. The county may process the student files and return eligibility information to the LEA as a provider. At a minimum, the LEA will need to provide the county with two or more of the following: The name, date of birth and Social Security Number for each individual for which eligibility information is sought. Additional information and requirements may differ depending on the arrangements made with individual county welfare offices.

• Point of Service (POS) device: Providers swipe a plastic Benefits Identification Card (BIC) through a machine that returns eligibility information on a receipt-like printout. Recipient information also may be keyed in by hand. Providers who are actively billing may be eligible to receive a POS device free of charge. Other providers may purchase a device. Additional information is available in the Point of Service (POS) section in the Part 1 Medi-Cal manual.

loc ed elig 3

2 – Local Educational Agency (LEA) Eligible Students Outpatient Services – LEA 391 May 2007

• Automated Eligibility Verification System (AEVS): This system is used by providers who want to verify eligibility for a small number of students by telephone. The only equipment required is a touch-tone telephone. LEAs will need to enter their NPI, the student’s Medi-Cal ID number, the student’s date of birth and the month of service for which the LEA is verifying eligibility.

Providers may make up to 10 eligibility inquiries per telephone call. The toll-free telephone number is 1-800-456-AEVS. Instructions for using AEVS are in the AEVS: General Instructions and AEVS: Transactions sections in the Part 1 Medi-Cal manual.

• Medi-Cal Web site on the Internet at www.medi-cal.ca.gov: A personal computer with a modem and a browser (for example Internet Explorer) is required. Providers may verify a recipient’s eligibility, clear Share of Cost liability and reserve Medi-Services by sending data via the Internet in a specific data format. To create eligibility batches for recipients seen on a monthly basis, providers may use the Internet Batch Eligibility Application (IBEA).

• Providers also may develop their own software or use software developed by a vendor to verify eligibility. A list of vendors who may develop eligibility verification systems is available in the CMC Developers, Vendors and Billing Services Directory on the Internet at www.medi-cal.ca.gov . To view the list, click the “Technical Specs” link and then the “CMC Developers, Vendors and Billing Services Directory” link.

http://www.medi-cal.ca.gov/

Local Educational Agency (LEA): loc ed indiv Individualized Plans 1

2 – Local Educational Agency (LEA): Outpatient Services – LEA 405 Individualized Plans June 2008

This section contains information about students’ Individualized Education Plans (IEPs) and Individualized Family Services Plans (IFSPs). IEPs and IFSPs are integral components to improving educational results for many students who are eligible for Local Educational Agency (LEA) Medi-Cal Billing Option Program services. IEP/IFSP Assessments Individualized Education Plan (IEP) and Individualized Family Services

Plan (IFSP) assessments are performed to determine a student’s eligibility for services under the Individuals with Disabilities Education Act (IDEA) or to obtain information about the student to identify and modify the health-related services in the IEP/IFSP. The following activities are required in an initial/triennial IEP/IFSP assessment.

• Review student records, such as cumulative files, health history, and/or medical records.

• Interview the student and/or parent/guardian.

• Observe the student in the classroom and other appropriate settings.

• Schedule and administer psychosocial tests, developmental tests, and/or physical health assessments. Score and interpret test results, as applicable.

• Write a report to summarize assessment results and recommendations for additional LEA services.

Activities performed for an annual or amended IEP/IFSP assessment

include all of the activities in an initial/triennial assessment, except for scheduling and administering psychosocial tests and the other tests noted in the 4th bullet above. Additional testing may or may not be conducted in a student’s annual or amended IEP/IFSP assessment.

The written assessment report and related case notes should be

maintained to document activities performed for each IEP/IFSP assessment.

loc ed indiv 2

2 – Local Educational Agency (LEA): Outpatient Services – LEA 418 Individualized Plans July 2009

Service Limitations The assessments a provider may perform are limited per service type, as follows:

Type Service Limitation Per Student, Per Service

and Per Provider

Initial IFSP One assessment per lifetime per provider may be billed

Initial/Triennial One assessment may be billed every IEP third state fiscal year

Annual One assessment may be billed every IEP/IFSP state fiscal year that an initial/triennial

assessment is not billed

Amended One assessment may be billed every IEP/IFSP 30 days

Local Educational Agency (LEA) loc ed rend Rendering Practitioner Qualifications 1

2 – Local Educational Agency (LEA) Outpatient Services – LEA 379 Rendering Practitioner Qualifications May 2006

This section outlines the qualifications for practitioners employed by LEAs who may render services under the Local Educational Agency (LEA) Medi-Cal Billing Option Program. Qualified LEA The following is a list of specific health professionals who are Rendering Practitioners qualified rendering practitioners under the LEA Medi-Cal Billing Option

Program.

1. Licensed registered nurse, including registered credentialed school nurse and certified public health nurse *

2. Certified nurse practitioner * 3. Licensed vocational nurse * 4. Trained health care aide 5. Licensed physician/psychiatrist 6. Licensed optometrist 7. Licensed clinical social worker * 8. Credentialed school social worker * 9. Licensed psychologist * 10. Licensed educational psychologist * 11. Credentialed school psychologist * 12. Licensed marriage and family therapist * 13. Credentialed school counselor * 14. Licensed physical therapist 15. Registered occupational therapist 16. Licensed speech-language pathologist 17. Speech-language pathologist with a valid credential 18. Licensed audiologist 19. Audiologist with a valid credential 20. Registered school audiometrist 21. Program specialist *

* LEA/Targeted Case Management (TCM) services may be rendered by LEA practitioners designated by an asterisk above. Practitioners who meet the qualifications of a program specialist as described in this section, may also provide TCM services. Additional information about billing TCM is located in the Local Educational Agency (LEA) Service: Targeted Case Management section in this manual.

Scope of Service The rendering practitioner scope of services for which LEAs

may be reimbursed is restricted as specified in charts titled Practitioner-Performed Assessment Services Reimbursable to LEAs and Practitioner-Performed Treatment and TCM Services Reimbursable to LEAs. The charts are included in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

loc ed rend 2

2 – Local Educational Agency (LEA) Outpatient Services – LEA 398 Rendering Practitioner Qualifications November 2007

Documenting Practitioner The LEA provider must maintain documented evidence of each Qualifications rendering practitioner’s license, certification, registration or credential

to practice in California. (Applies to all except trained health care aide practitioners.)

Suspended Medi-Cal Suspended Medi-Cal providers may not render LEA services. For Providers Excluded information about suspended providers, refer to the Suspended and

Ineligible Providers List, which is available on the Internet at www.medi-cal.ca.gov.

Rendering Practitioner Rendering practitioner qualifications are defined in the California Qualifications Code of Regulations (CCR), the California Education Code, the Business and Professions Code, the Welfare and Institutions Code,

and the Health and Safety Code. Specific qualifications and service descriptions for contracted licensed

practitioners employed by non-public schools and agencies are listed in CCR, Title 5, Sections 3065 and 3029 and Education Code, Section 49402. These references distinguish the qualifications between employees of LEAs and contracted practitioners.

Information about practitioner credentials issued by the California

Commission on Teacher Credentialing is available in The Administrator’s Assignment Manual, available at www.ctc.ca.gov.

loc ed rend 3

2 – Local Educational Agency (LEA) Outpatient Services – LEA 413 Rendering Practitioner Qualifications February 2009

Registered Credentialed Registered credentialed school nurses must be licensed to practice School Nurses by the California Board of Registered Nursing. Qualified practitioners

must have a school nurse services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990. Effective January 1, 1981, these nurses also must show proof they have child abuse and neglect detection training. This requirement may be fulfilled through continuing education.

Business and Professions Code, Section 2701 and Education Code,

Sections 49422(a), 49426 and 44877. Licensed Registered Registered nurses (RNs) must be licensed to practice by the Nurses California Board of Registered Nursing. RNs who do not have a

school nurse services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990 may render LEA services if supervised by a registered credentialed school nurse.

CCR, Title 22, Section 51067. Certified Public Certified public health nurses must be licensed and certified as public Health Nurses health nurses by the California Board of Registered Nursing. Certified

public health nurses who do not have a school nurse services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990 may render LEA services if supervised by a registered credentialed school nurse. Certified public heath nurses providing specialized physical health care services as specified in California Education Code, Section 49423.5 may render LEA services without supervision.

CCR, Title 16, Section 1491. Certified Nurse Certified nurse practitioners must be licensed and certified to practice Practitioners as nurse practitioners, whose practices are predominantly that of

primary care, by the California Board of Registered Nursing. Certified nurse practitioners who do not have a school nurse services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990 may render LEA services if supervised by a registered credentialed school nurse.

CCR, Title 22, Section 51170.3.

loc ed rend 4

2 – Local Educational Agency (LEA) Outpatient Services – LEA 413 Rendering Practitioner Qualifications February 2009

Licensed Vocational Nurses Licensed vocational nurses (LVNs) must be licensed to practice by the California Board of Vocational Nursing and Psychiatric Technicians. LVNs providing specialized physical health care must practice under the direction of a licensed physician, registered credentialed school nurse or certified public health nurse as specified in Education Code, Section 49423.5.

Business and Professions Code, Section 2841. Trained Health Trained health care aides must be trained in the administration of Care Aides specialized physical health care as specified in California Education

Code, Section 49423.5 and may render LEA services only if supervised by a licensed physician or surgeon, a registered credentialed school nurse or a certified public health nurse.

Licensed Physicians Physicians must be licensed to practice by the Medical Board of and Psychiatrists California or the Osteopathic Medical Board of California. Physicians

employed on a half-time or greater than half-time basis must have a health services credential or a valid credential issued prior to November 23, 1970.

Education Code, Section 44873. Licensed Optometrists Optometrists must be licensed by the California Board of Optometry

and must have a services credential with a specialization in health or a valid credential issued prior to November 23, 1970.

Business and Professions Code, Section 3041.2(a) and Education

Code, Section 44878.

loc ed rend 5


Licensed Clinical Licensed clinical social workers must be licensed to practice by Social Workers the California Board of Behavioral Sciences. Clinical social workers

must have a pupil personnel services credential with a specialization in school social work, a health services credential, or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Business and Professions Code, Sections 4990.15 and 4996 and

Education Code, Sections 44874 and 49422(a).

Contracted licensed clinical social workers employed by non-public schools and agencies must be licensed to practice by the California Board of Behavioral Sciences or possess a pupil personnel services credential with a specialization in school social work.

CCR, Title 5, Section 3065. Credentialed School Credentialed school social workers must have a pupil personnel Social Workers services credential with a specialization in school social work or a valid

credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990. Credentialed school social workers may provide psychosocial treatment services only to the extent authorized under Business and Professions Code, Sections 4996, 4996.9, 4996.14 and 4996.15 and Education Code, Section 44874, to Medi-Cal eligible students.

Education Code, Section 49422(a). Licensed Psychologists Licensed psychologists must be licensed to practice by the California Board of Psychology. These practitioners must have a pupil personnel

services credential with a specialization in school psychology, a health services credential, or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Business and Professions Code, Sections 2902(b) and 2903 and

Education Code, Sections 44874 and 49422(a). Contracted licensed psychologists employed by non-public schools

and agencies must be licensed to practice by the California Board of Psychology or possess a pupil personnel services credential with a specialization in school psychology.

CCR, Title 5, Sections 3065 and 3029.

loc ed rend 6


Licensed Educational Licensed educational psychologists must be licensed to practice by Psychologists the California Board of Behavioral Sciences. These practitioners must

have a pupil personnel services credential with a specialization in school psychology or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Business and Professions Code, Sections 4980.03(a) and 4989.10

and Education Code, Section 49422(a). Contracted licensed educational psychologists employed by non-public

schools and agencies must be licensed to practice by the California Board of Behavioral Sciences or possess a pupil personnel services credential with a specialization in school psychology.

CCR, Title 5, Sections 3065 and 3029. Credentialed School Credentialed school psychologists must have a pupil personnel Psychologists services credential with a specialization in school psychology or a valid

credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990. Credentialed school psychologists may provide psychological treatment services only to the extent authorized under Business and Professions Code, Section 2910 and Education Code, Sections 49422 and 49424, to Medi-Cal eligible students.

Education Code, Section 49422(a). Licensed Marriage Licensed marriage and family therapists must be licensed to practice and Family Therapists by the California Board of Behavioral Sciences. These practitioners

must have a pupil personnel services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Business and Professions Code, Sections 4980(b) and 4980.03(a) and

Education Code, Section 49422(a). Contracted licensed marriage and family therapists employed by

non-public schools and agencies must be licensed to practice by the California Board of Behavioral Sciences or possess a pupil personnel services credential. CCR, Title 5, Section 3065.

loc ed rend 7


Credentialed School Credentialed school counselors must have a valid pupil personnel Counselors services credential with a specialization in school counseling or a valid

credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Education Code, Sections 49422(a) and 49600(a). Licensed Physical Therapists Licensed physical therapists must be licensed to practice by the

California Physical Therapy Board. Physical therapists must be graduates of a physical therapist education program accredited by the Commission on Accreditation in Physical Therapy Education of the American Physical Therapy Association.

Business and Professions Code, Sections 2601, 2632 and 2651. Registered Occupational Registered occupational therapists must be licensed to practice by Therapists the California Board of Occupational Therapy. Occupational therapists

must be graduates of an educational program for occupational therapists that is accredited by the American Occupational Therapy Association’s Accreditation Council for Occupational Therapy Education (ACOTE).

Business and Professions Code, Sections 2570.2(d), 2570.2(g) and

2570.6(b)(1).

loc ed rend 8


Licensed Speech-Language Licensed speech-language pathologists must be licensed to practice Pathologists by the California Speech-Language Pathology and Audiology Board. Business and Professions Code, Sections 2530.2(a) and 2532 and

Education Code, Section 44831. Speech-Language Speech-language pathologists must have a valid clinical or Pathologists rehabilitative services credential with an authorization in language,

speech and hearing or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990. Speech-language pathologists with a valid credential may provide assessment and treatment services related to speech, voice, language or swallowing disorders. These services must be provided under the direction of licensed speech-language pathologists only to the extent authorized under Business and Professions Code, Sections 2530.2, 2530.5 and 2532 and Education Code, Sections 44225 and 44268, to Medi-Cal eligible students.

Education Code, Section 49422(a). Licensed Audiologists Licensed audiologists must be licensed to practice by the

California Speech-Language Pathology and Audiology Board. These practitioners must have a clinical or rehabilitative services credential with an authorization in audiology or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990.

Business and Professions Code, Sections 2530.2(a) and 2532 and

Education Code, Section 49422(a).

loc ed rend 9


Audiologists Audiologists must have a clinical or rehabilitative services credential with an authorization in audiology or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990. Audiologists with a valid credential may provide audiological and communication disorders assessments and treatment services. These services must be provided under the direction of licensed audiologists only to the extent authorized under Business and Professions Code, Section 2530.2 and 2530.5 and 2532 and Education Code, Sections 44225 and 44268, to Medi-Cal eligible students.

Education Code, Section 49422(a). Registered School School audiometrists must have a valid certificate of registration Audiometrists issued by the Department of Health Care Services (DHCS). Education Code, Section 44879 and Health and Safety Code,

Section 1685. Program Specialists Program specialists must have a baccalaureate or higher degree from

an accredited institution of higher education. These practitioners must also complete a post baccalaureate professional preparation program in accordance with requirements to qualify for a valid special education credential, clinical or rehabilitative services credential, health services credential or a school psychologist authorization.

Education Code, Sections 44266, 44267, 44268 and 56368 and CCR,

Title 5, Section 80048.2.

Local Educational Agency (LEA) loc ed serv hear Service: Hearing 1

2 – Local Educational Agency (LEA) Service: Hearing Outpatient Services – LEA 379 May 2006

This section contains information about audiology services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.

• Qualifications that practitioners must meet to render services are outlined in the Local Educational Agency (LEA) Rendering Practitioner Qualifications section of this manual.

• Modifier descriptions are located in the Modifiers: Approved List section of this manual. Additional modifier information is in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

• Individualized Education Plan (IEP) and Individualized Family Services Plan (IFSP) are defined in the Local Educational Agency (LEA): Individualized Plans section of this manual.

Audiology Services Audiology is the application of principles, methods and procedures of

measurement, testing, appraisal, prediction, consultation, counseling, instruction related to auditory, vestibular and related functions and the modification of communicative disorders involving speech, language, auditory behavior or other aberrant behavior resulting from auditory dysfunction.

Covered Services Audiology services include:

• IEP/IFSP audiological assessments (evaluations) • Non-IEP/IFSP hearing assessments (includes screening

test – pure tone and pure tone audiometry – threshold) • Audiology treatment and hearing checks

loc ed serv hear 2


Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by the indicated qualified practitioner(s).

Qualified Practitioners Reimbursable Services

Licensed audiologists

Audiologists

IEP/IFSP audiological assessments (evaluations)

Non-IEP/IFSP hearing assessments (includes screening test – pure tone and pure tone audiometry – threshold)

Audiology treatment and hearing checks

Licensed physicians/psychiatrists

Licensed speech-language pathologists

Speech-language pathologists

Registered school audiometrists

Registered credentialed school nurses (who are also registered school audiometrists)

Non-IEP/IFSP hearing assessments (includes screening test – pure tone and pure tone audiometry – threshold)

loc ed serv hear 3

2 – Local Educational Agency (LEA) Service: Hearing Outpatient Services – LEA 388 February 2007

Referrals Audiological assessments (evaluations) and hearing assessments (screenings) require a written referral by a physician or dentist, within the practitioner’s scope of practice (California Code of Regulations, Title 22, Section 51309[a]). The written referral must be maintained in the student’s files. In substitution of a written referral, a registered credentialed school nurse, teacher or parent may refer the student for an assessment. The registered credentialed school nurse, teacher or parent referral must be documented in the student’s files.

Audiology treatment services require a written referral by a physician, dentist or licensed audiologist within the practitioner’s scope of practice (CCR, Title 22, Section 51309[a] and 42 Code of Federal Regulations, Section 440.110[c]). If a written referral is provided by a licensed audiologist, the LEA must also develop and implement Physician Based Standards (see “Physician Based Standards” in this section for more information). The written referral must be maintained in the student’s files. For students covered by an IEP or IFSP, the physician, dentist or licensed audiologist referral may be established and documented in the student’s IEP or IFSP.

Physician Based If the individual written referral is provided by a licensed audiologist, Standards the LEA must develop and implement Physician Based Standards.

Physician Based Standards must establish minimum standards of medical need for referrals to audiology treatment services. The standards must be reviewed and approved by a physician. Additionally, the LEA must ensure that the standards are subsequently reviewed/revised and approved by a physician no less than once every two years. The following documentation must be maintained and available for State and/or Federal review.

• In each student’s file:

− A copy of the cover letter signed by the physician that states the physician reviewed and approved the protocol standards. The cover letter must include contact information for the physician.

− Proof that the services rendered are consistent with the protocol standards.

• In the LEA’s file:

− A printed copy of the protocol standards.

− Contact information for individuals responsible for developing the protocol standards.

− Contact information for the practitioners who have reviewed and rely upon the protocol standards to document medical necessity.

loc ed serv hear 4


Supervision Requirements The following chart indicates whether a rendering practitioner requires supervision to provide audiology services.

Qualified Practitioner Supervision Requirement

Licensed audiologist No supervision required to provide audiology services

Audiologist with a valid clinical or rehabilitative services credential with an authorization in audiology or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990

Requires supervision by a licensed audiologist to provide audiology services

Licensed physician/psychiatrist Licensed speech-language pathologist Registered school audiometrist

No supervision required to provide hearing assessments (screenings)

Speech-language pathologist with a valid clinical or rehabilitative services credential with an authorization in language, speech and hearing or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990

Requires supervision by a licensed speech-language pathologist to provide hearing assessments (screenings)

loc ed serv hear 5


Supervising Speech-Language The supervising licensed speech-language pathologist or licensed Pathologist and/or Audiologist audiologist must be individually involved with patient care and accept

responsibility for the actions of the credentialed speech-language pathologist or credentialed audiologist under his or her supervision. The amount and type of supervision required should be consistent with the skills and experience of the credentialed speech-language pathologist or credentialed audiologist, and with the standard of care necessary to provide appropriate patient treatment.

The annual duties of the supervising speech-language pathologist or

audiologist include, but are not limited to:

• Periodically observing assessments, evaluation and therapy

• Periodically observing preparation and planning activities

• Periodically reviewing client and patient records and monitoring and evaluating assessment and treatment decisions of the credentialed speech-language pathologist or credentialed audiologist

The licensed practitioner must see each patient at least once, have

some input into the type of care provided, and review the patient after treatment has begun.

A licensed speech-language pathologist or audiologist must be

available by telephone (conventional or cellular) during the workday to consult with the credentialed speech-language pathologist or credentialed audiologist, as needed.

loc ed serv hear 6

2 – Local Educational Agency (LEA) Service: Hearing Outpatient Services – LEA 418 July 2009

Service Limitations: Annual Audiology services that are not authorized in a student’s IEP or IFSP are limited to 24 services (assessment, treatment or transportation

services) per state fiscal year per student.

Audiology services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year.

Claim completion: Information about modifiers to ensure accurate

processing of services rendered under an IEP or IFSP is located in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

Service Limitations: Daily Audiology treatment services are limited to 24 units per student per

day. This daily limitation includes a maximum of three initial service increments (3 x 15 = 45 minutes) and 21 additional service increments.

Non-IEP/IFSP hearing assessments (screenings) are limited to one

per student per day. IEP/IFSP hearing checks are limited to one per student per day. Initial and Additional One audiology treatment initial service per provider per day may be Treatment Services billed. The initial service for audiology treatment is based on 15 – 45

continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service; all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on

the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (CCR, Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 or HCPCS code. If the student receives more than one treatment session per day (for example, two audiology treatment sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.

loc ed serv hear 7

2 – Local Educational Agency (LEA) Service: Hearing Outpatient Services – LEA 418 July 2009

Procedure Codes/Service The following chart contains the CPT-4 or HCPCS procedure codes Limitations Chart: with modifiers, if necessary, to bill for audiology services. The Audiology Services “Qualified Practitioner” text in italics indicates that an additional

modifier (beyond those already indicated in the “Procedure Code/Modifier” column) must be entered on the claim to identify the type of practitioner who rendered the service. Service limitations also are included.

Reimbursement rates for these services are in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual.


LEA Program Usage

LEA Limitations (Per Student)

IEP/IFSP Assessments (Evaluations)

92506 TL (IFSP) Initial IFSP audiological assessment

One per lifetime per provider

92506 TM (IEP) Initial or triennial IEP audiological assessment

One every third state fiscal year per provider

92506 52 TL (IFSP) or

92506 52 TM (IEP)

Annual IEP/IFSP audiological assessment

One every state fiscal year per provider when an initial or triennial

IEP/IFSP audiological assessment is not billed


92506 TS TM (IEP)

Amended IEP/IFSP audiological assessment

One every 30 days per provider

Non-IEP/IFSP Assessments (Screenings)

Qualified Practitioners (Modifier): Licensed physician/psychiatrist (AG) Licensed speech-language pathologist (GN) Speech-language pathologist (GN) Licensed audiologist (no modifier) Audiologist (no modifier) Registered school audiometrist (no modifier) Registered credentialed school nurse (who is also a registered school audiometrist) (TD)

92551 Hearing assessment, per encounter

(screening test, pure tone, air only)

One per day

24 services (assessment, treatment or transportation services) per

state fiscal year 92552 Hearing assessment,

per encounter (pure tone audiometry,

threshold, air only)

One per day


state fiscal year

loc ed serv hear 8

2 – Local Educational Agency (LEA) Service: Hearing Outpatient Services – LEA 388 February 2007


LEA Program Usage


Treatments

92507 TL (IFSP) or

92507 TM (IEP) or


Audiology initial service, 15 − 45

continuous minutes (bill 1 unit per


3 units per day

See “Service Limitations: Annual” for additional information

92507 22 TL (IFSP) or

92507 22 TM (IEP) or


Audiology service, additional 15-minute

increment

21 units per day


V5011 TL (IFSP) or

V5011 TM (IEP)

Hearing check One per day


Local Educational Agency (LEA) loc ed serv nurs Service: Nursing 1

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 382 August 2006

This section contains information about nursing and school health aide services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Nursing and School Nursing services include functions such as basic health care Health Aide Services associated with actual or potential health or illness problems or the

treatment thereof. Nursing services include all of the following:

• Direct and indirect patient care services that ensure the safety and protection of patients; and the performance of disease prevention and restorative measures

• The administration of medications and therapeutic agents necessary to implement a treatment, disease prevention or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist as defined by Section 1316.5 of the Health and Safety Code

• The performance of skin tests, immunization techniques and the withdrawal of human blood from veins and arteries

• Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition that may result in the determination of abnormal characteristics, and implementation of appropriate reporting, referral, standardized procedures, or changes in treatment regimen in accordance with standardized procedures

loc ed serv nurs 2

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 379 May 2006

Covered Services Nursing services include:

• IEP/IFSP health assessments • Non-IEP/IFSP health/nutrition assessments, health

education/anticipatory guidance and vision assessments • Nursing and school health aide treatment services

Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by nurses and trained health care aides.


Registered credentialed school nurses

IEP/IFSP health assessments

Non-IEP/IFSP health nutrition assessments, health education/ anticipatory guidance and vision assessments

Nursing treatments

Licensed registered nurses

Certified public health nurses

Certified nurse practitioners

Licensed vocational nurses

Nursing treatments

Trained health care aides School health aide treatments

Recommendations The following services require a recommendation by a physician

or registered credentialed school nurse. The recommendation must be documented in the student’s files. In substitution of a recommendation, a teacher or parent may refer the student for an assessment. The teacher or parent referral must be documented in the student’s files.

• Health assessments • Health/nutrition assessments • Health education/anticipatory guidance • Vision assessments

loc ed serv nurs 3

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 413 February 2009

Supervision Requirements The following chart indicates whether a rendering practitioner requires supervision to provide nursing or school health care aide services.


Registered credentialed school nurse

No supervision required to provide nursing services

The following practitioners if they do not have a valid school nurse services credential or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990:

Licensed registered nurse

Certified public health nurse

Certified nurse practitioner

Requires supervision by a registered credentialed school nurse to provide nursing services

Note: Certified public health nurses do not require supervision by a registered credentialed school nurse to provide specialized physical health care services

Licensed vocational nurse Requires supervision by a licensed physician, registered credentialed school nurse or certified public health nurse to provide nursing treatment services

Trained health care aide Requires supervision by a licensed physician or surgeon, registered credentialed school nurse or certified public health nurse to provide school health aide treatment services

loc ed serv nurs 4

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 418 July 2009

Service Limitations: Annual Nursing and school health aide services that are not authorized in a student’s IEP or IFSP are limited to 24 services (assessment,

treatment or transportation services) per state fiscal year per student.

Nursing and school aide services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year.



Service Limitations: Daily Each type of nursing treatment service (including nursing services

provided by RNs and LVNs) and school health aide treatment services (provided by trained health care aides) is limited to 32 units per student per day.

Each type of non-IEP/IFSP assessment (including health/nutrition and

health education/anticipatory guidance) is limited to four units per student per day.

Non-IEP/IFSP vision assessments are limited to one per student per

day. Treatment Services Nursing treatment services and school health aide treatment services Billed Using 15-Minute are billed in 15-minute increments and do not have separate initial and Increments additional service increments. When seven or more continuous

treatment minutes are rendered, a 15-minute increment can be billed (California Code of Regulations, Title 22, Sections 51507[b][5] and 51507.1[b][4]).

loc ed serv nurs 5

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 418 July 2009

Procedure Codes/Service The following chart contains the CPT-4 or HCPCS procedure codes Limitations Chart: with modifiers, if necessary, to bill for nursing and school health aide Nursing and School services. Service limitations also are included. Health Aide Services


Procedure Code/

Modifier LEA Program

Usage LEA Limitations

(Per Student)


T1001 TL (IFSP) Initial IFSP health assessment


T1001 TM (IEP) Initial or triennial IEP health assessment


T1001 52 TL (IFSP) or

T1001 52 TM (IEP)

Annual IEP/IFSP health assessment

One every state fiscal year per provider when an initial or triennial IEP/IFSP health assessment is not

billed T1001 TS TL (IFSP)

or T1001 TS TM (IEP)

Amended IEP/IFSP health assessment



96150 TD Health/nutrition assessment, each


4 units per day


state fiscal year 96151 TD Health/nutrition

re-assessment, each completed 15-minute

increment

4 units per day


state fiscal year 99401 TD Health

education/anticipatory guidance, each

completed 15-minute increment (applies to

both initial and re-assessment)

4 units per day


state fiscal year

99173 TD Vision assessment One per day


state fiscal year

loc ed serv nurs 6

2 – Local Educational Agency (LEA) Service: Nursing Outpatient Services – LEA 388 February 2007


LEA Program Usage


Treatments

T1002 TL (IFSP) or

T1002 TM (IEP) or


Nursing services, RN, 15-minute increment

32 units per day


T1003 TL (IFSP) or

T1003 TM (IEP) or


Nursing services, LVN, 15-minute

increment

32 units per day


T1004 TL (IFSP) or

T1004 TM (IEP) or


School health aide services, 15-minute

increment

32 units per day


Local Educational Agency (LEA) loc ed serv occu Service: Occupational Therapy 1

2 – Local Educational Agency (LEA) Service: Occupational Therapy Outpatient Services – LEA 379 May 2006

This section contains information about occupational therapy services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Occupational Therapy Occupational therapy is the therapeutic use of goal-directed activities

(occupations) that maximize independence, prevent or minimize disability and maintain health. Occupational therapy services include occupational therapy assessment, treatment, education and consultative services. Occupational therapy assessment identifies performance abilities and limitations that are necessary for self-maintenance, learning, work and other similar meaningful activities. Occupational therapy treatment is focused on developing, improving or restoring functional daily living skills, compensating for and preventing dysfunction or minimizing disability.

Covered Services Occupational therapy services include:

• IEP/IFSP occupational therapy assessments • Non-IEP/IFSP developmental assessments • Occupational therapy treatments

loc ed serv occu 2

2 – Local Educational Agency (LEA) Service: Occupational Therapy Outpatient Services – LEA 382 August 2006

Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by a registered occupational therapist.


Registered occupational therapists

IEP/IFSP occupational therapy assessments

Non-IEP/IFSP developmental assessments

Occupational therapy treatments

Prescriptions Occupational therapy assessments and developmental assessments

require a written prescription by a physician or podiatrist, within the practitioner’s scope of practice (California Code of Regulations [CCR], Title 22, Section 51309[a]). The written prescription must be maintained in the student’s files. In substitution of a written prescription, a registered credentialed school nurse, teacher or parent may refer the student for an assessment. The registered credentialed school nurse, teacher or parent referral must be documented in the student’s files.

Occupational therapy treatment services require a written prescription

by a physician or podiatrist, within the practitioner’s scope of practice (CCR, Title 22, Section 51309[a]). The written prescription must be maintained in the student’s files. For students covered by an IEP or IFSP, the physician or podiatrist prescription may be established and documented in the student’s IEP or IFSP.

Supervision Requirements Registered occupational therapists do not require supervision to

provide occupational therapy services.

loc ed serv occu 3

2 – Local Educational Agency (LEA) Service: Occupational Therapy Outpatient Services – LEA 418 July 2009

Service Limitations: Annual Occupational therapy services that are not authorized in a student’s IEP or IFSP are limited to 24 services (assessment, treatment or

transportation services) per state fiscal year per student.

Occupational therapy services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year. Claim completion: Information about modifiers to ensure accurate processing of services rendered under an IEP or IFSP is located in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

Service Limitations: Daily Occupational therapy treatment services are limited to 24 units per

student per day. This daily limitation includes a maximum of three initial service increments (3 units x 15 minutes = 45 minutes) and 21 additional service increments.

Non-IEP/IFSP developmental assessments are limited to four units per student per day.

Initial and Additional One occupational therapy initial service per provider per day may be Treatment Services billed. The initial service for occupational therapy treatment is based

on 15 – 45 continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service; all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (CCR, Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 code. If the student receives more than one treatment session per day (for example, two occupational therapy treatment sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.

loc ed serv occu 4

2 – Local Educational Agency (LEA) Service: Occupational Therapy Outpatient Services – LEA 418 July 2009

Procedure Codes/Service The following chart contains the CPT-4 procedure codes with Limitations Chart: modifiers, if necessary, to bill for occupational therapy services. Occupational Therapy Service limitations also are included. Services



LEA Program Usage



97003 TL (IFSP) Initial IFSP occupational therapy

assessment


97003 TM (IEP) Initial or triennial IEP occupational therapy

assessment


97003 52 TL (IFSP) or

97003 52 TM (IEP)

Annual IEP/IFSP occupational therapy

assessment


IEP/IFSP occupational therapy assessment is not billed

97004 TL (IFSP) or

97004 TM (IEP)

Amended IEP/IFSP occupational therapy

assessment



96110 GO Developmental assessment, each

completed 15-minute increment (applies to initial assessment and

re-assessment)

4 units per day


state fiscal year

Treatments

97110 GO TL (IFSP) or

97110 GO TM (IEP) or

97110 GO (non-IEP/IFSP)

Occupational therapy initial service, 15 – 45 continuous minutes


3 units per day


97110 22 GO TL (IFSP)

or 97110 22 GO TM

(IEP) or

97110 22 GO (non-IEP/IFSP)

Occupational therapy service, additional

15-minute increment

21 units per day


Local Educational Agency (LEA) loc ed serv phy Service: Physical Therapy 1

2 – Local Educational Agency (LEA) Service: Physical Therapy Outpatient Services – LEA 379 May 2006

This section contains information about physical therapy services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Physical Therapy Physical therapy is the physical or corrective rehabilitation or physical

or corrective treatment of any bodily or mental condition of a person by the use of physical, chemical and other properties of heat, light, water, electricity or sound and by massage and active, resistive or passive exercise. Physical therapy includes evaluation, treatment planning, instruction and consultative services.

Covered Services Physical therapy services include:

• IEP/IFSP physical therapy assessments • Non-IEP/IFSP developmental assessments • Physical therapy treatments

loc ed serv phy 2

2 – Local Educational Agency (LEA) Service: Physical Therapy Outpatient Services – LEA 382 August 2006

Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by a licensed physical therapist.


Licensed physical therapists IEP/IFSP physical therapy assessments

Non-IEP/IFSP developmental assessments

Physical therapy treatments Prescriptions Physical therapy assessments and developmental assessments

require a written prescription by a physician or podiatrist, within the practitioner’s scope of practice (California Code of Regulations [CCR], Title 22, Section 51309[a]). The written prescription must be maintained in the student’s files. In substitution of a written prescription, a registered credentialed school nurse, teacher or parent may refer the student for an assessment. The registered credentialed school nurse, teacher or parent referral must be documented in the student’s files.

Physical therapy treatment services require a written prescription by a

physician or podiatrist, within the practitioner’s scope of practice (CCR, Title 22, Section 51309[a]). The written prescription must be maintained in the student’s files. For students covered by an IEP or IFSP, the physician or podiatrist prescription may be established and documented in the student’s IEP or IFSP.

Supervision Requirements Licensed physical therapists do not require supervision to provide

physical therapy services.

loc ed serv phy 3

2 – Local Educational Agency (LEA) Service: Physical Therapy Outpatient Services – LEA 418 July 2009

Service Limitations: Annual Physical therapy services that are not authorized in a student’s IEP or IFSP are limited to 24 services (assessment, treatment or


Physical therapy services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year. Claim completion: Information about modifiers to ensure accurate processing of services rendered under an IEP or IFSP is located in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

Service Limitations: Daily Physical therapy treatment services are limited to 24 units per student

per day. This daily limitation includes a maximum of three initial service increments (3 units x 15 minutes = 45 minutes) and 21 additional service increments.

Non-IEP/IFSP developmental assessments are limited to four units per student per day.

Initial and Additional One physical therapy initial service per provider per day may be Treatment Services billed. The initial service for physical therapy treatment is based on

15 – 45 continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service; all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (CCR, Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 code. If the student receives more than one treatment session per day (for example, two physical therapy treatment sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.

loc ed serv phy 4

2 – Local Educational Agency (LEA) Service: Physical Therapy Outpatient Services – LEA 418 July 2009

Procedure Codes/Service The following chart contains the CPT-4 procedure codes with Limitations Chart: modifiers, if necessary, to bill for physical therapy services. Physical Therapy Service limitations also are included. Services



LEA Program Usage



97001 TL (IFSP) Initial IFSP physical therapy assessment


97001 TM (IEP) Initial or triennial IEP physical therapy

assessment


97001 52 TL (IFSP) or

97001 52 TM (IEP)

Annual IEP/IFSP physical therapy

assessment


IEP/IFSP physical therapy assessment is not billed

97002 TL (IFSP) or 97002 TM (IEP)

Amended IEP/IFSP physical therapy

assessment



96110 GP Developmental assessment, each


re-assessment)

4 units per day


state fiscal year

Treatments

97110 GP TL (IFSP) or

97110 GP TM (IEP) or

97110 GP (non-IEP/IFSP)

Physical therapy initial service, 15 – 45

continuous minutes (bill 1 unit per


3 units per day


97110 22 GP TL (IFSP)

or 97110 22 GP TM

(IEP) or

97110 22 GP (non-IEP/IFSP)

Physical therapy service, additional

15-minute increment

21 units per day


Local Educational Agency (LEA) loc ed serv physician Service: Physician Billable Procedures 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Physician Billable Procedures May 2006

This section contains information about physician/psychiatrist services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Physician/Psychiatrist Physicians diagnose and treat diseases, injuries, deformities and Services other physical or mental conditions. Covered Services Physician/psychiatrist services include:

• IEP/IFSP health/nutrition assessments • Non-IEP/IFSP health/nutrition assessments, health

education/anticipatory guidance, vision assessments and hearing assessments (includes screening test – pure tone and pure tone audiometry – threshold)

• Psychology and counseling treatments, including individual and group treatments

loc ed serv physician 2


Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by a licensed physician/psychiatrist.


Licensed physicians/ psychiatrists

IEP/IFSP health/nutrition assessments

Non-IEP/IFSP health/nutrition assessments, health education/anticipatory guidance, vision assessments and hearing assessments (includes screening test – pure tone and pure tone audiometry – threshold)

Psychology and counseling treatments, including individual and group treatments

Recommendations The following services require a recommendation by a physician

or registered credentialed school nurse. The recommendation must be documented in the student’s files. In substitution of a recommendation, a teacher or parent may refer the student for an assessment. The teacher or parent referral must be documented in the student’s files.

• Health/nutrition assessments • Health education/anticipatory guidance • Hearing assessments (screenings) • Vision assessments

Psychology and counseling treatment services require a

recommendation by one of the following practitioners, within the practitioner’s scope of practice (Code of Federal Regulations, Title 42, Section 440.130[d]). The recommendation must be documented in the student’s files. For students covered by an IEP or IFSP, the recommendation may be established and documented in the student’s IEP or IFSP.

• Physician • Registered credentialed school nurse • Licensed clinical social worker • Licensed psychologist • Licensed educational psychologist • Licensed marriage and family therapist


2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Physician Billable Procedures July 2009

Supervision Requirements Licensed physicians/psychiatrists do not require supervision to provide physician services.

Service Limitations: Annual Physician/psychiatrist services that are not authorized in a student’s

IEP or IFSP are limited to 24 services (assessment, treatment or transportation services) per state fiscal year per student.

Physician services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year.





Service Limitations: Daily Psychology/counseling treatment services are limited to 24 units per student per day. This daily limit includes a maximum of three initial service increments (3 units x 15 minutes = 45 minutes) and 21 additional service increments.

Each type of non-IEP/IFSP assessment (including health/nutrition and

health education/anticipatory guidance) is limited to four units per student per day.

Non-IEP/IFSP vision assessments are limited to one per student per

day. Non-IEP/IFSP hearing assessments (screenings) are limited to one

per student per day. Initial and Additional An LEA provider may bill each type of psychology/counseling initial Treatment Services service (individual or group) once per student per day. The initial

service for psychology/counseling is based on 15 – 45 continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service, all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on

the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (California Code of Regulations, Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 code. If the student receives more than one treatment session per day (for example, two psychology/counseling treatment sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.



Procedure Codes/Service The following chart contains the CPT-4 procedure codes with Limitations Chart: modifiers, if necessary, to bill for physician services. Service Physician Services limitations also are included.


Procedure Code/



(Per Student)


96150 AG TL (IFSP) Initial IFSP health/nutrition

assessment, each completed 15-minute

increment


96150 AG TM (IEP) Initial or triennial IEP health/nutrition


increment


96150 52 AG TL (IFSP)

or 96150 52 AG TM

(IEP)

Annual IEP/IFSP health/nutrition


increment


IEP/IFSP health/nutrition assessment is not billed

96151 AG TL (IFSP) or

96151 AG TM (IEP)

Amended IEP/IFSP health/nutrition


increment





LEA Program Usage



96150 AG Health/nutrition assessment, each


4 units per day


state fiscal year 96151 AG Health/nutrition


increment

4 units per day


state fiscal year 99401 AG Health

education/anticipatory guidance, each

completed 15-minute increment (applies to


4 units per day


state fiscal year

99173 AG Vision assessment One per day



per encounter (screening test, pure

tone, air only)

One per day





One per day


state fiscal year


2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Physician Billable Procedures February 2007


LEA Program Usage


Treatments


96152 AG TM (IEP) or

96152 AG (non-IEP/IFSP)


continuous minutes, individual (bill 1 unit

per 15-minute increment)

3 units per day


96152 22 AG TL (IFSP)

or 96152 22 AG TM

(IEP) or

96152 22 AG (non-IEP/IFSP)

Psychology/ counseling additional, 15 minute increment,

individual

21 units per day



96153 AG TM (IEP) or

96153 AG (non-IEP/IFSP)


continuous minutes, group (bill 1 unit per


3 units per day


96153 22 AG TL (IFSP)

or 96153 22 AG TM

(IEP) or

96153 22 AG (non-IEP/IFSP)

Psychology/ counseling additional, 15 minute increment,

group

21 units per day


Local Educational Agency (LEA) loc ed serv psych Service: Psychology/Counseling 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Psychology/Counseling May 2006

This section contains information about psychology and counseling services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Psychology and Psychology and counseling involves the application of psychological Counseling Services principles, methods and procedures of understanding, predicting and

influencing behavior, such as the principles pertaining to learning, perception, motivation, emotion and interpersonal relationships. It includes diagnosis, prevention, treatment and amelioration of psychological problems and emotional and mental disorders.

Covered Services Psychology and counseling services include:

• IEP/IFSP psychological assessments and psychosocial status assessments

• Non-IEP/IFSP psychosocial status assessments and health education/anticipatory guidance

• Psychology and counseling treatments, including individual and group treatments

loc ed serv psych 2


Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by the indicated qualified practitioner(s).


Licensed psychologists

Licensed educational psychologists

Credentialed school psychologists

IEP/IFSP psychological assessments

Non-IEP/IFSP psychosocial status assessments and health education/anticipatory guidance


Licensed clinical social workers

Credentialed school social workers

Licensed marriage and family therapists

IEP/IFSP psychosocial status assessments



Credentialed school counselors IEP/IFSP psychosocial status assessments



Non-IEP/IFSP health education/anticipatory guidance



Non-IEP/IFSP health education/anticipatory guidance

loc ed serv psych 3


Recommendations Psychological assessments, psychosocial status assessments and health education/anticipatory guidance require a recommendation by one of the following practitioners, within the practitioner’s scope of practice (Code of Federal Regulations, Title 42, Section 440.130[d]). The recommendation must be documented in the student’s files. In substitution of a recommendation, a teacher or parent may refer the student for an assessment. The teacher or parent referral must be documented in the student’s files.


Psychology and counseling treatment services require a

recommendation by one of the following practitioners, within the practitioner’s scope of practice (Code of Federal Regulations, Title 42, Section 440.130[d]). The recommendation must be documented in the student’s files. For students covered by an IEP or IFSP, the recommendation may be established and documented in the student’s IEP or IFSP.


loc ed serv psych 4

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Psychology/Counseling July 2009

Supervision Requirements The following practitioners do not require supervision to provide psychology and counseling services:

• Licensed psychologists • Licensed educational psychologists • Credentialed school psychologists • Licensed clinical social workers • Credentialed school social workers • Licensed marriage and family therapists • Credentialed school counselors • Licensed physicians/psychiatrists • Registered credentialed school nurses

Service Limitations: Annual Psychology and counseling services that are not authorized in a

student’s IEP or IFSP are limited to 24 services (assessment, treatment or transportation services) per state fiscal year per student.

Psychology and counseling services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year.



loc ed serv psych 5


Service Limitations: Daily Psychology/counseling treatment services are limited to 24 units per student per day. This daily limitation includes a maximum of three initial service increments (3 units x 15 minutes = 45 minutes) and 21 additional service increments.

Each type of non-IEP/IFSP assessment (including psychosocial status assessments and health education/anticipatory guidance) is limited to four units per student per day.

Initial and Additional An LEA provider may bill each type of psychology/counseling initial Treatment Services service (individual or group) once per student per day. The initial

service for psychology/counseling is based on 15 – 45 continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service; all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (California Code of Regulations [CCR], Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 code. If the student receives more than one treatment session per day (for example, two psychology/counseling therapy treatment sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.

loc ed serv psych 6


Procedure Codes/Service The following chart contains the CPT-4 procedure codes with Limitations Chart: modifiers, if necessary, to bill for psychology and counseling Psychology and services. The “Qualified Practitioner” text in italics indicates Counseling Services that an additional modifier (beyond those already indicated in the

“Procedure Code/Modifier” column) must be entered on the claim to identify the type of practitioner who rendered the service. Service limitations also are included.


Procedure Code/



(Per Student)


Psychological Assessment Qualified Practitioners (Modifier): Licensed psychologist (no modifier) Licensed educational psychologist (no modifier) Credentialed school psychologist (no modifier)

96101 TL (IFSP) Initial IFSP psychological assessment


96101 TM (IEP) Initial or triennial IEP psychological assessment


96101 52 TL (IFSP) or

96101 52 TM (IEP)

Annual IEP/IFSP psychological assessment


IEP/IFSP psychological assessment is not billed


96101 TS TM (IEP)

Amended IEP/IFSP psychological assessment


loc ed serv psych 7



LEA Program Usage


IEP/IFSP Assessments (continued)

Psychosocial Status Assessment Qualified Practitioners (Modifier): Licensed clinical social worker (AJ) Credentialed school social worker (AJ) Licensed marriage & family therapist (no modifier) Credentialed school counselor (no modifier)

96150 TL (IFSP) Initial IFSP psychosocial status assessment, each



96150 TM (IEP) Initial or triennial IEP psychosocial status assessment, each



96150 52 TL (IFSP) or

96150 52 TM (IEP)

Annual IEP/IFSP psychosocial status assessment, each



IEP/IFSP psychosocial status assessment is not billed

96151 TL (IFSP) or 96151 TM (IEP)

Amended IEP/IFSP psychosocial status assessment, each



loc ed serv psych 8



LEA Program Usage



Psychosocial Status Assessment Qualified Practitioners (Modifier): Licensed psychologist (AH) Licensed educational psychologist (AH) Credentialed school psychologist (AH) Licensed clinical social worker (AJ) Credentialed school social worker (AJ) Licensed marriage & family therapist (no modifier) Credentialed school counselor (no modifier)

96150 Psychosocial status assessment, each


4 units per day


state fiscal year 96151 Psychosocial status


increment

4 units per day


state fiscal year Health Education/Anticipatory Guidance Qualified Practitioners (Modifier): Licensed psychologist (AH) Licensed educational psychologist (AH) Credentialed school psychologist (AH) Licensed clinical social worker (AJ) Credentialed school social worker (AJ) Licensed marriage & family therapist (no modifier) Credentialed school counselor (no modifier) Licensed physician/psychiatrist (AG) Registered credentialed school nurse (TD)

99401 Health education/anticipatory

guidance, each completed 15-minute increment (applies to


4 units per day


state fiscal year

loc ed serv psych 9

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Psychology/Counseling February 2007


LEA Program Usage


Treatments

Qualified Practitioners (Modifier): Licensed psychologist (AH) Licensed educational psychologist (AH) Credentialed school psychologist (AH) Licensed clinical social worker (AJ) Credentialed school social worker (AJ) Licensed marriage & family therapist (no modifier) Licensed physician/psychiatrist (AG)

96152 TL (IFSP) or

96152 TM (IEP) or


Psychology/counseling initial service, 15 – 45 continuous minutes,

individual (bill 1 unit per 15-minute increment)

3 units per day


96152 22 TL (IFSP) or

96152 22 TM (IEP) or


Psychology/counseling additional 15-minute increment, individual

21 units per day


96153 TL (IFSP) or

96153 TM (IEP) or


Psychology/counseling initial service, 15 – 45 continuous minutes, group (bill 1 unit per


3 units per day


96153 22 TL (IFSP) or

96153 22 TM (IEP) or


Psychology/counseling additional 15-minute

increment, group

21 units per day


Local Educational Agency (LEA) loc ed serv spe Service: Speech Therapy 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Speech Therapy May 2006

This section contains information about speech therapy services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Speech Therapy Speech therapy is the application of principles, methods and

instrumental and noninstrumental procedures for measurement, testing, screening, evaluation, identification, prediction and counseling related to the development and disorders of speech, voice, language or swallowing. Speech-language services also include preventing, planning, directing, conducting and supervising programs for habilitating, rehabilitating, ameliorating, managing or modifying disorders of speech, voice, language or swallowing and conducting hearing screenings.

Covered Services Speech therapy services include:

• IEP/IFSP speech-language assessments • Non-IEP/IFSP developmental assessments and hearing

assessments (includes screening test – pure tone and pure tone audiometry – threshold)

• Speech therapy treatments, including individual and group treatments

loc ed serv spe 2

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Speech Therapy February 2007

Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by a licensed speech-language pathologist or

speech-language pathologist.


Licensed speech-language pathologists

Speech-language pathologists

IEP/IFSP speech-language assessments

Non-IEP/IFSP developmental assessments and hearing assessments (includes screening test – pure tone and pure tone audiometry – threshold)

Speech therapy treatments, including individual and group treatments

Referrals Speech-language assessments, developmental assessments and

hearing assessments (screenings) require a written referral by a physician or dentist within the practitioner’s scope of practice (California Code of Regulations [CCR], Title 22, Section 51309[a]). The written referral must be maintained in the student’s files. In substitution of a written referral, a registered credentialed school nurse, teacher or parent may refer the student for an assessment. The registered credentialed school nurse, teacher or parent referral must be documented in the student’s files.

Speech therapy treatment services require a written referral by a physician, dentist or licensed speech-language pathologist within the practitioner’s scope of practice (CCR, Title 22, Section 51309[a] and 42 Code of Federal Regulations, Section 440.110[c]). If a written referral is provided by a licensed speech-language pathologist, the LEA must also develop and implement Physician Based Standards (see “Physician Based Standards” in this section for more information). The written referral must be maintained in the student’s files. For students covered by an IEP or IFSP, the physician, dentist or licensed speech-language pathologist referral may be established and documented in the student’s IEP or IFSP.

loc ed serv spe 3

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 386 Speech Therapy December 2006

Physician Based If the individual written referral is provided by a licensed Standards speech-language pathologist, the LEA must develop and implement

Physician Based Standards. Physician Based Standards must establish minimum standards of medical need for referrals to speech therapy treatment services. The standards must be reviewed and approved by a physician. Additionally, the LEA must ensure that the standards are subsequently reviewed/revised and approved by a physician no less than once every two years. The following documentation must be maintained and available for State and/or Federal review.

• In each student’s file:

− A copy of the cover letter signed by the physician that states the physician reviewed and approved the protocol standards. The cover letter must include contact information for the physician.

− Proof that the services rendered are consistent with the protocol standards.

• In the LEA’s file:

− A printed copy of the protocol standards.

− Contact information for individuals responsible for developing the protocol standards.

− Contact information for the practitioners who have reviewed and rely upon the protocol standards to document medical necessity.

loc ed serv spe 4

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Speech Therapy May 2006

Supervision Requirements The following chart indicates whether a rendering practitioner requires supervision to provide speech therapy services.


Licensed speech-language pathologist

No supervision required to provide speech therapy services

Speech-language pathologist with a valid clinical or rehabilitative services credential with an authorization in language, speech and hearing or a valid credential issued prior to the operative date of Section 25 of Chapter 557 of the Statutes of 1990

Requires supervision by a licensed speech-language pathologist to provide speech therapy services

Supervising Speech-Language The supervising licensed speech-language pathologist must be Pathologist individually involved with patient care and accept responsibility for the

actions of the credentialed speech-language pathologist under his or her supervision. The amount and type of supervision required should be consistent with the skills and experience of the credentialed speech-language pathologist and with the standard of care necessary to provide appropriate patient treatment.

The annual duties of the supervising speech-language pathologist

include, but are not limited to:

• Periodically observing assessments, evaluation and therapy

• Periodically observing preparation and planning activities

• Periodically reviewing client and patient records and monitoring and evaluating assessment and treatment decisions of the credentialed speech-language pathologist

The licensed practitioner must see each patient at least once, have

some input into the type of care provided, and review the patient after treatment has begun.

A licensed speech-language pathologist must be available by

telephone (conventional or cellular) during the workday to consult with the credentialed speech-language pathologist, as needed.

loc ed serv spe 5

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Speech Therapy July 2009

Service Limitations: Annual Speech therapy services that are not authorized in a student’s IEP or IFSP are limited to 24 services (assessment, treatment or


Speech therapy services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the 24 services per state fiscal year. The state fiscal year begins on July 1 of each year. Claim completion: Information about modifiers to ensure accurate processing of services rendered under an IEP or IFSP is located in the Local Educational Agency (LEA) Billing and Reimbursement Overview section of this manual.

Service Limitations: Daily Speech therapy treatment services are limited to 24 units per student

per day. This daily limitation includes a maximum of three initial service increments (3 x 15 = 45 minutes) and 21 additional service increments. Non-IEP/IFSP developmental assessments are limited to four units per student per day. Non-IEP/IFSP hearing assessments (screenings) are limited to one per student per day.

Initial and Additional An LEA provider may bill each type of speech therapy initial service Treatment Services (individual or group) once per student per day. The initial service for

speech therapy is based on 15 – 45 continuous minutes; one unit may be billed for each 15-minute increment. A maximum of three units may be billed for the initial service; all units are reimbursable under one initial service maximum allowable rate.

Additional services are billed when more than 45 minutes are spent on the initial service. Additional services are billed in time increments of 15 minutes, and may be rounded up when seven or more continuous minutes are provided (CCR, Title 22, Sections 51507[b][5] and 51507.1[b][4]). Additional LEA services must be billed in conjunction with an initial service treatment CPT-4 code. If the student receives more than one treatment session per day (for example, two speech therapy sessions at different times during the day), the total treatment time for the second session must be billed as additional treatment services.

loc ed serv spe 6

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Speech Therapy July 2009

Procedure Codes/Service The following chart contains the CPT-4 procedure codes with Limitations Chart: modifiers, if necessary, to bill for speech therapy services. Speech Therapy Service limitations also are included.


Procedure Code/



(Per Student)


92506 GN TL (IFSP) Initial IFSP speech-language

assessment


92506 GN TM (IEP) Initial or triennial IEP speech-language

assessment


92506 52 GN TL (IFSP)

or 92506 52 GN TM

(IEP)

Annual IEP/IFSP speech-language

assessment


IEP/IFSP speech-language assessment is not billed

92506 TS GN TL (IFSP)

or 92506 TS GN TM

(IEP)

Amended IEP/IFSP speech-language

assessment



96110 GN Developmental assessment, each


re-assessment)

4 units per day


state fiscal year

92551 GN Hearing assessment, per encounter

(screening test, pure tone, air only)

One per day


state fiscal year 92552 GN Hearing assessment,



One per day


state fiscal year

loc ed serv spe 7

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Speech Therapy February 2007


LEA Program Usage


Treatments

92507 GN TL (IFSP) or

92507 GN TM (IEP) or

92507 GN (non-IEP/IFSP)

Speech therapy initial service, 15 − 45

continuous minutes, individual


3 units per day


92507 22 GN TL (IFSP)

or 92507 22 GN TM

(IEP) or

92507 22 GN (non-IEP/IFSP)


15-minute increment, individual

21 units per day


92508 GN TL (IFSP) or

92508 GN TM (IEP) or

92508 GN (non-IEP/IFSP)

Speech therapy initial service, 15 – 45

continuous minutes, group (bill 1 unit per


3 units per day


92508 22 GN TL (IFSP)

or 92508 22 GN TM

(IEP) or

92508 22 GN (non-IEP/IFSP)


15-minute increment, group

21 units per day


Local Educational Agency (LEA) loc ed serv targ Service: Targeted Case Management 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Targeted Case Management May 2006

This section contains information about targeted case management (TCM) services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program. Components of TCM include determining student needs, developing a plan of care and coordinating services, including assessing services outside the school system.




Targeted Case Targeted case management services assist eligible children and Management Services eligible family members to access needed medical, social,

educational and other services when TCM is covered by the student’s IEP or IFSP.

Components The components of TCM include: Determining needs. Evaluating health and mental health assessments

and meeting with the student and parent(s) or guardian(s) to establish the following needs:

• Physical and mental health • Physical necessities, such as food and clothing • Social and emotional • Housing and physical environment • Family and social support • Conservatorship • Socialization and recreational • Training for community living • Educational and vocational

Note: “Determining needs” is not performing the assessment but determining the needs or services required by analyzing the results of the assessment.

loc ed serv targ 2

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Targeted Case Management May 2006

Developing plan. Writing a comprehensive, individualized service plan in consultation with the student and parent(s) or guardian(s), which includes:

• Objectives • Actions designed to meet student’s needs • Referral list (programs, agencies, people) • Details about the nature, frequency and duration of activities

to achieve objectives Linking and consulting coordination. Coordinating services by:

• Consulting with qualified service providers, including linkage and referral to appropriate services

• Following up to determine if the services were received and if the student’s needs were met (The follow-up should occur promptly and at least 30 days after referral dates.)

Accessing services outside the school system. Arranging, executing

or obtaining:

• Appointments and/or transportation for medical, social, educational and other services

• Language translation services to facilitate communication between client (or on behalf of client) and case manager or other rendering provider

• Placement contracts • Approval for medical treatment

Assisting with crises. Intervening in circumstances by:

• Accommodating unusual situations that require immediate attention to avoid, eliminate or reduce a crisis situation

• Arranging and coordinating emergency services or treatments

Note: Assistance for problems that can be handled in a safe, procedural manner by school personnel, such as a sudden illness or serious injury, is not included.

Reviewing progress. Reviewing the case management plan

periodically to determine if the plan is to be continued, modified or discontinued. The review must:

• Occur at least every six months • Include consultation with the student and/or parent

and guardian • Have a written addendum when modified

TCM does not include diagnostic or treatment services, educational

activities that may be reasonably expected in the school system, administrative activities or program activities that do not meet the definition of TCM.

loc ed serv targ 3

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 397 Targeted Case Management October 2007

Coordinating TCM The Department of Health Care Services (DHCS) recommends that each Medi-Cal eligible student is assigned one case manager who has the ability to provide students with comprehensive TCM services. However, it is recognized that some students will receive TCM services from more than one agency or provider. To avoid duplication of services and billing, LEAs must do the following:

• Clearly document the LEA and TCM services rendered by each

TCM agency or provider, and

• Where necessary, develop written agreements to define the case management service(s) each agency and/or provider will be responsible for rendering.

Supervision Requirements The following practitioners do not require supervision to provide

TCM services:

• Registered credentialed school nurses

• Licensed registered nurses

• Certified public health nurses

• Certified nurse practitioners

• Licensed vocational nurses

• Licensed clinical social workers

• Credentialed school social workers

• Licensed psychologists

• Licensed educational psychologists

• Credentialed school psychologists

• Licensed marriage and family therapists

• Credentialed school counselors

• Program specialists

loc ed serv targ 4

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Targeted Case Management July 2009

Service Limitations: Annual TCM services that are authorized in a student’s IEP or IFSP and documented as medically necessary may be rendered beyond the

24 services per state fiscal year. The state fiscal year begins on July 1 of each year. Claim completion: Information about modifiers to ensure accurate


Service Limitations: Daily TCM services are limited to 32 units per student per day. TCM Services Billed TCM services are billed in 15-minute increments and do not have Using 15-Minute separate initial and additional service increments. When seven or Increments more continuous treatment minutes are rendered, a 15-minute

increment can be billed (California Code of Regulations, Title 22, Sections 51507[b][5] and 51507.1[b][4]).

loc ed serv targ 5

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Targeted Case Management February 2007

Procedure Codes/Service The following chart contains the HCPCS procedure codes, with Limitations Chart: modifiers, to bill for targeted case management services. The Targeted Case “Qualified Practitioner” text in italics indicates that an additional Management modifier (beyond those already indicated in the “Procedure

Code/Modifier” column) must be entered on the claim to identify the type of practitioner who rendered the service. Service limitations also are included.


Procedure Code/



(Per Student)


Qualified Practitioners (Modifier): Registered credentialed school nurses (TD) Licensed registered nurses (TD) Certified public health nurses (TD) Certified nurse practitioners (TD) Licensed vocational nurses (TE) Licensed clinical social workers (AJ) Credentialed school social workers (AJ) Licensed psychologists (AH) Licensed educational psychologists (AH) Credentialed school psychologists (AH) Licensed marriage and family therapists (no modifier) Credentialed school counselors (no modifier) Program specialists (HO)

T1017 TL (IFSP) or

T1017 TM (IEP)

Targeted case management, low cost

provider, 15-minute increment

32 units per day


T1017 TL (IFSP) or

T1017 TM (IEP)

Targeted case management, medium

cost provider, 15-minute increment

32 units per day


T1017 TL (IFSP) or

T1017 TM (IEP)

Targeted case management, high

cost provider, 15-minute increment

32 units per day


Local Educational Agency (LEA) loc ed serv trans Service: Transportation (Medical) 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Transportation (Medical) May 2006

This section contains information about medical transportation services rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.



Medical Transportation LEA medical transportation must be provided in a litter van or Services wheelchair van for students with or without an IEP or IFSP. Criteria Litter van transportation is appropriate and reimbursable when the

student’s medical and/or physical condition:

• Requires the student to be transported in a prone or supine position because the student is not able to sit for the time needed to transport.

• Requires specialized equipment and more space than available in passenger cars, taxicabs or other forms of public transportation.

• Does not require the specialized services, equipment and personnel of an ambulance because the student is stabilized and does not need constant observation.

Wheelchair van transportation is appropriate and reimbursable when

the student’s medical and/or physical condition:

• Renders the student unable to sit in a private vehicle, taxicab or other form of public transportation for the time needed for transport.

• Requires that the student be transported in a wheelchair.

• Does not require the specialized services, equipment and personnel of an ambulance because the student is in stable condition and does not need constant observation.

loc ed serv trans 2

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Transportation (Medical) July 2009

Covered Services Medical transportation services include:

• Medical transportation (trip) • Mileage (must be in conjunction with trip)

The reimbursement rate is per trip and a trip is considered

one way. Providers bill one unit of service per one-way trip (2 units = round trip).

Note: Both transportation (trip) and mileage in a litter van or

wheelchair van are reimbursable for students whether or not they are authorized in a student’s IEP or IFSP. Additional information is available in “Service Limitations: Annual” in this section.

Service Limitations: Medical transportation services that are not authorized in a student’s Annual IEP or IFSP are limited to 24 services (assessment, treatment or

transportation service) per state fiscal year per student. The state fiscal year begins on July 1 of each year. LEA medical transportation and LEA mileage reimbursement are restricted to trips between the school and the location where health services are provided.

Note: Transportation between home and school is not covered. Medical transportation services that are authorized in a student’s IEP

or IFSP and documented as medically necessary may be billed beyond the 24 services per state fiscal year. The following conditions must be met on the day of service for the

transportation service to be reimbursed:

• The student must receive a Medicaid-covered service (other than transportation) at the service site, and

• Both the covered service and the transportation must be authorized in the student’s IEP or IFSP.

Note: Transportation between home and school is covered when the

above conditions are met. Claim completion: Information about modifiers to ensure accurate


loc ed serv trans 3

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 388 Transportation (Medical) February 2007

Mileage Limitations Mileage reimbursement for students with or without an IEP or IFSP is covered for trips in a litter van or wheelchair van only. The reimbursement rate is per mile. Mileage will be reimbursed only when billed in conjunction with medical transportation (HCPCS code T2003). Mileage that is not authorized in a student’s IEP or IFSP may be billed only for trips between the school and location where health services are rendered. Mileage that is authorized in a student’s IEP or IFSP may be billed when the student is transported to and from the residence to an LEA, and to and from the location where health services are rendered.

Procedure Codes/Service The following chart contains the HCPCS procedure codes with Limitations Chart: Medical modifiers, if necessary, to bill for medical transportation services. Transportation Services Service limitations also are included.


Procedure Code/



(Per Student)

Medical Transportation

T2003 TL (IFSP) or

T2003 TM (IEP) or


Medical transportation,

per one-way trip, wheelchair van or

litter van


A0425 TL (IFSP) or

A0425 TM (IEP) or

A0425 (non-IEP/IFSP)

Mileage, per mile No limitation

Local Educational Agency (LEA) loc ed serv vis Service: Vision Assessments 1

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 379 Vision Assessments May 2006

This section contains information about vision assessments rendered in connection with the Local Educational Agency (LEA) Medi-Cal Billing Option Program.




Optometry Services Optometry includes the prevention and diagnosis of disorders and

dysfunctions of the visual system. Covered Services Optometry services include:

• Non-IEP/IFSP vision assessments Rendering Practitioners: The following chart indicates the services that are reimbursable to Reimbursable Services LEAs when performed by the indicated qualified practitioner(s).


Licensed optometrists



Non-IEP/IFSP vision assessments

loc ed serv vis 2

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Vision Assessments July 2009

Recommendations Vision assessments require a recommendation by a physician or registered credentialed school nurse. The recommendation must be documented in the student’s files. In substitution of a recommendation, a teacher or parent may refer the student for an assessment. The teacher or parent referral must be documented in the student’s files.

Supervision Requirements The following practitioners do not require supervision to provide vision

assessments:

• Licensed optometrists • Licensed physicians/psychiatrists • Registered credentialed school nurses

Service Limitations: Annual Non-IEP/IFSP vision assessments are limited to 24 services (assessment, treatment or transportation services) per state fiscal year

per student. The state fiscal year begins on July 1 of each year. Service Limitations: Daily Non-IEP/IFSP vision assessments are limited to one per student

per day.

loc ed serv vis 3

2 – Local Educational Agency (LEA) Service: Outpatient Services – LEA 418 Vision Assessments July 2009

Procedure Codes/Service The following chart contains the CPT-4 procedure code to bill for Limitations Chart: vision assessments. The “Qualified Practitioner” text in italics Vision Assessments indicates that a modifier must be entered on the claim to identify the

type of practitioner who rendered the service. Service limitations also are included. Reimbursement rates for these services are in the Local Educational Agency (LEA) Billing Codes and Reimbursement Rates section of this manual.

Procedure Code/



(Per Student)


Qualified Practitioners (Modifier): Licensed physician/psychiatrist (AG) Registered credentialed school nurse (TD) Licensed optometrist (no modifier)

99173 Vision assessment One per day


state fiscal year

modif app Modifiers: Approved List 1

2 – Modifiers: Approved List June 2011

Below is a list of approved modifier codes for use in billing Medi-Cal. Modifiers not listed in this section are unacceptable for billing Medi-Cal. Modifier Overview Some modifier information in this section is taken from the CPT-4

code book (Current Procedural Terminology – 4th Edition) and HCPCS code book (Healthcare Common Procedure Coding System, Level II).

Discontinued Modifiers Medicaid programs have traditionally tailored modifiers for their state’s

needs. These interim (or local) modifiers are being phased out under HIPAA requirements. Refer to the list of discontinued and invalid modifiers at the end of this section.

National Correct Medi-Cal claims are subject to a set of claims processing edits that Coding Initiative are federally mandated. The edits, controlled by the Centers for

Medicare & Medicaid Services (CMS), are part of the National Correct Coding Initiative (NCCI). Modifiers relevant to the NCCI edit methodology are designated “NCCI associated” in the following modifier list. See the Correct Coding Initiative: National section for how NCCI affects reimbursement. Note: NCCI does not allow more than one NCCI-associated modifier

on a line for Treatment Authorization Requests (TARs), CMS-1500 claims and UB-04 claims. TARs and claims containing two or more NCCI-associated modifiers on

the same line will be denied. In addition, placement of modifiers on the claim is important. An NCCI-associated modifier should not appear in the first modifier position (next to the procedure code) unless it is the only modifier on that claim line.

modif app 2

* Check the CPT-4 book for guidelines in using this modifier. 2 – Modifiers: Approved List

July 2011

Approved Modifier

National Modifier Description Program-Specific Use of the Modifier and Special Considerations

8A CFTR (cystic fibrosis) This modifier is only used for prenatal screening of cystic fibrosis.

22* Increased procedural services May be used with computed tomography (CT) codes when additional slices are required or a more detailed evaluation is necessary.

Used by Local Educational Agency (LEA) to denote an additional 15-minute service increment rendered beyond the required initial service time. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

Surgical: May be billed when procedures involve significantly increased operative complexity and/or time in a significantly altered surgical field resulting from the effects of prior surgery, marked scarring, adhesions, inflammation, or distorted anatomy, irradiation, infection, very low weight (for example, neonates and small infants less than 10 kg) and/or trauma (as documented in a recipient’s medical record). Justification is required on the claim.

24* Unrelated E&M service by the same physician during a postoperative period

25* NCCI associated

Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service

26* Professional component

modif app 3


March 2011

Approved Modifier


27* NCCI associated

Increased procedural services

47* Anesthesia by surgeon Do not use as a modifier for anesthesia codes.

50* Bilateral procedure

51* Multiple procedures

52* Reduced services Surgical: For use with surgery codes 66820 – 66821, 66830, 66840, 66850, 66920, 66930, 66940 and 66982 – 66985. Requires “By Report” documentation. Used by LEA to denote an annual re-assessment. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information. LEA does not require “By Report” documentation.

53* Discontinued procedure Requires “By Report” documentation.

54* Surgical care only Surgical: Use only with surgery codes 66820 – 66821, 66830, 66840, 66850, 66920, 66930, 66940 and 66982 – 66985. Requires “By Report” documentation.

55* Postoperative management only

58* NCCI associated

Staged or related procedure or service by the same physician during the postoperative period

May be used with codes 15002 – 15431 and 52601 to address subsequent part(s) of a staged procedure.

modif app 4


March 2011

Approved Modifier


59* NCCI associated

Distinct procedural service Used primarily with codes 36818 – 36819 and 76816. Also used with other codes, as appropriate, for NCCI purposes.

62* Two surgeons

66* Surgical team

73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia (to be reported by hospital outpatient department or surgical clinic, only)

To be reported by hospital outpatient department or surgical clinic only. Requires “By Report” documentation.

74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia

To be reported by hospital outpatient department or surgical clinic only. Requires “By Report” documentation.

76* Repeat procedure or service by same physician

77* Repeat procedure by another physician

78* NCCI associated

Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period

modif app 5


March 2011

Approved Modifier


79* NCCI associated

Unrelated procedure or service by the same physician during the postoperative period

80* Assistant surgeon

90* Reference (outside) laboratory Only specified providers may use this modifier.

91* NCCI associated

Repeat clinical diagnostic laboratory test

99* Multiple modifiers Used when two or more modifiers are necessary to completely delineate a service; the multiple modifiers used must be explained in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim. Also used in special circumstances as specified by the Department of Health Care Services (DHCS). For an example, refer to the Surgery Billing Examples: UB-04 or Surgery Billing Examples: CMS-1500 sections in the appropriate Part 2 manual.

modif app 6

2 – Modifiers: Approved List March 2011

Approved Modifier


AG Primary physician Surgical: Used to denote a primary surgeon. In the case of multiple primary surgeons, two or more surgeons can use modifier AG for the same patient on the same date of service if the procedures are performed independently and in different specialty areas. This does not include surgical teams or surgeons performing a single procedure requiring different skills. An explanation of the clinical situation and operative reports by all surgeons involved must be included with the claim. Used by LEA to denote licensed physicians/psychiatrists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

AH Clinical psychologist Used by LEA to denote licensed psychologists, licensed educational psychologists and credentialed school psychologists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

AI Principal physician of record Allowable for all procedure codes.

AJ Clinical social worker Used by LEA to denote licensed clinical social workers and credentialed school social workers. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination

Use only for ophthalmology.

modif app 7


Approved Modifier


E1 NCCI associated

Upper left, eyelid Use modifier SC with CPT-4 code 68761 (closure of lacrimal punctum; by thermocauterization, ligation, or laser surgery; by plug, each) to indicate use of temporary collagen punctal plugs. Modifiers E1 thru E4 are used in connection with permanent silicone punctal plugs and procedures on the eyelids.

E2 NCCI associated

Lower left, eyelid Same as above

E3 NCCI associated

Upper right, eyelid Same as above

E4 NCCI associated

Lower right, eyelid Same as above

ET Emergency services

F1 NCCI associated

Left hand, second digit

F2 NCCI associated

Left hand, third digit

F3 NCCI associated

Left hand, fourth digit

F4 NCCI associated

Left hand, fifth digit

modif app 8


Approved Modifier


F5 NCCI associated

Right hand, thumb

F6 NCCI associated

Right hand, second digit

F7 NCCI associated

Right hand, third digit

F8 NCCI associated

Right hand, fourth digit

F9 NCCI associated

Right hand, fifth digit

FA NCCI associated

Left hand, thumb

GN Service delivered under an outpatient speech-language pathology plan of care

Used by LEA to denote licensed speech-language pathologists and speech-language pathologists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

GO Service delivered under an outpatient occupational therapy plan of care

Used by LEA to denote registered occupational therapists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

modif app 9


Approved Modifier


GP Service delivered under an outpatient physical therapy plan of care

Used by LEA to denote licensed physical therapists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

GQ Via asynchronous telecommunications system

Used to denote store-and-forward telecommunications system.

GT Via interactive audio and video telecommunications systems

Used to denote real-time telecommunications system.

GY Item or service statutorily excluded; does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit

Used to denote that the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) recipient with full-scope Medi-Cal has started a physician-ordered course of treatment before reaching 21 years of age and the recipient is to complete the course of the prescribed treatment; OR the recipient started a physician-ordered course of treatment before July 1, 2009 and required additional time to complete treatment after this date. GY is to be used ONLY for services exempted from the optional benefits exclusion policy.

Use of GY only applies to medical/surgical care required for the treatment and the resolution of the acute episode.

modif app 10


Approved Modifier


HA Child/adolescent program Used by pediatric subacute facility to denote that the patient is a child.

HB Adult program, nongeriatric Used by adult subacute facility to denote that the patient is an adult.

HO Masters degree level Used by LEA to denote program specialists. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

HT Multi-disciplinary team Used by California Community Transition (CCT) Demonstration providers to denote CCT services.

J4 DMEPOS item subject to DMEPOS competitive bidding program that is furnished by a hospital upon discharge

Allowable but not required for all DME codes.

KC Replacement of special power wheelchair interface

KX Requirements specified in the medical policy have been met

Specific required documentation on file.

modif app 11


Approved Modifier


LC NCCI associated

Left circumflex coronary artery

LD NCCI associated

Left anterior descending coronary artery

LT NCCI associated

Left side (used to identify procedures performed on the left side of the body)

NU New equipment Used to denote purchase of new equipment.

P1* A normal, healthy patient Used to denote anesthesia services provided to a normal, uncomplicated patient.

P3* A patient with severe systemic disease

Used to denote anesthesia services provided to a patient with severe systemic disease.

P4* A patient with severe systemic disease that is a constant threat to life

Used to denote anesthesia services provided to a patient with severe systemic disease that is a constant threat to life.

P5* A moribund patient who is not expected to survive without the operation

Used to denote anesthesia services provided to a moribund patient who is not expected to survive without the operation.

modif app 12


Approved Modifier


PA Surgery, wrong body part Allowable for all procedure codes.

PB Surgery, wrong patient Allowable for all procedure codes.

PC Wrong surgery on patient Allowable for all procedure codes.

PI Positron emission tomography (PET) or PET/computed tomography (CT) to inform initial treatment strategy of tumors

Allowable but not required for all radiology procedure codes.

PS PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors

Allowable but not required for all radiology procedure codes.

QE Prescribed amount of oxygen is less than one liter per minute (LPM)

QF Prescribed amount of oxygen exceeds four liters per minute (LPM) and portable oxygen is prescribed

QG Prescribed amount of oxygen is greater than four liters per minute (LPM)

Use this modifier if portable oxygen is NOT prescribed.

modif app 13

2 – Modifiers: Approved List April 2011

Approved Modifier


QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals

Note: Modifier QK will also be used when billing for the supervision of one anesthesia procedure.

QP Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes 80002 – 80019, G0058, G0059 and G0060

Used for lab codes where documentation is on file showing that the test was ordered individually.

QS Monitored anesthesia care service Used by California Children’s Services (CCS) to denote monitored anesthesia care.

QW CLIA waived test Used to certify that the provider is performing testing for the procedure with the use of a specific test kit from manufacturers identified by the Centers for Medicare & Medicaid Services (CMS).

QX CRNA service: with medical direction by a physician

QZ CRNA service: without medical direction by a physician

RA Replacement Used to indicate replacement vision care frames and lenses.

RB Replacement as part of a repair Used to indicate replacement parts during repair of Durable Medical Equipment (DME), including parts of eyeglass frames.

modif app 14


Approved Modifier


RC NCCI associated

Right coronary artery

RR Rental Used to indicate when DME is to be rented.

RT NCCI associated

Right side (used to identify procedures performed on the right side of the body)

SA Nurse practitioner rendering service in collaboration with a physician

SB Nurse midwife Used when Certified Nurse Midwife service is billed by a physician, hospital outpatient department or organized outpatient clinic (not by CNM billing under his or her own provider number).

SC Medically necessary service or supply

SE State and/or federally funded programs/services

SK Member of high-risk population (use only with codes for immunization)

SL State-supplied vaccine Used for Vaccines For Children (VFC) program recipients younger than 18 years of age.

modif app 15


Approved Modifier


T1 NCCI associated

Left foot, second digit

T2 NCCI associated

Left foot, third digit

T3 NCCI associated

Left foot, fourth digit

T4 NCCI associated

Left foot, fifth digit

T5 NCCI associated

Right foot, great toe

T6 NCCI associated

Right foot, second digit

T7 NCCI associated

Right foot, third digit

T8 NCCI associated

Right foot, fourth digit

T9 NCCI associated

Right foot, fifth digit

modif app 16


Approved Modifier


TA NCCI associated

Left foot, great toe

TC Technical component

TD Registered nurse (RN)

TE Licensed practical nurse (LPN)/Licensed vocational nurse (LVN)

Used by LEA to denote licensed vocational nurses. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

Used by Pediatric Palliative Care Waiver Program (PPCWP) to denote licensed vocational nurses providing services to children receiving palliative care services.

TH Obstetrical treatment/services, prenatal or postpartum

Used to denote that the service rendered is ONLY for pregnancy-related services and services for the treatment of other conditions that might complicate the pregnancy. Modifier TH can be used for up to 60 days after termination of pregnancy. TH is to be used ONLY for services exempted from the optional benefits exclusion policy.

TL Early intervention/Individualized Family Services Plan (IFSP)

Used by LEA to denote that service is part of IFSP. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

TM

Individualized Education Plan (IEP)

Used by LEA to denote that service is part of individualized education plan. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

modif app 17


Approved Modifier


TS Follow-up service Used by LEA to denote an amended re-assessment. See Local Educational Agency (LEA) in the appropriate Part 2 manual for more information.

TT Individualized service provided to more than one patient in same setting

Used by Home and Community-Based Services (HCBS) Waiver Program to denote services provided to two HCBS Nursing Facility/Acute Hospital (NF/AH) Waiver recipients who reside in the same residence. Also referred to as shared services.

U1 Medicaid level of care 1, as defined by each state

Used by HCBS Waiver Program to denote skilled nursing services A or B level of care.


Used by HCBS Waiver Program to denote subacute level of care.


Used by HCBS Waiver Program to denote acute level of care.


Used by HCBS Waiver Program to separate California Community Transitions (CCT) services from other waiver services.


Used to denote services rendered by Physician Assistant (PA).

modif app 18


Approved Modifier


UA Medicaid level of care 10, as defined by each state

Used for surgical or non-general anesthesia related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code.

Also used to indicate outpatient heroin detoxification services per visit, days 1 – 7. See the Heroin Detoxification Billing Codes section for details.

UB Medicaid level of care 11, as defined by each state

Used for surgical or general anesthesia related supplies and drugs, including surgical trays and plaster casting supplies, provided in conjunction with a surgical procedure code.

Also used to indicate outpatient heroin detoxification services per visit, days 8 – 21. See the Heroin Detoxification Billing Codes section for details.

UC Medicaid level of care 12, as defined by each state

Used to indicate outpatient heroin detoxification services once per week, days 8 – 21 (in lieu of UB). See the Heroin Detoxification Billing Codes section for details.

UD Medicaid level of care 13, as defined by each state

Used by Section 340B providers to denote services provided or drugs purchased under this program.

UJ Services provided at night

UN Two patients served

UP Three patients served

UQ Four patients served

UR Five patients served

US Six or more patients served

modif app 19


Approved Modifier


V5 Any vascular catheter (alone or with any other vascular access)

Allowable for all procedure codes.

V6 Arteriovenous graft (or other vascular access not including a vascular catheter)


V7 Arteriovenous fistula only (in use with two needles)


V8 Infection present Allowable for all procedure codes.

V9 No infection present Allowable for all procedure codes.

YW Not applicable. This is an interim (local) modifier.

Required professional experience (applies only to speech therapists and audiologists)

Z1 Not applicable. This is an interim (local) modifier.

Additional air mileage in excess of 10 percent of standard airway mileage distances. Reason for additional mileage flown must be documented on the claim or on an attachment.

modif app 20


Approved Modifier


ZL Not applicable. This is an interim (local) modifier.

This modifier is used to certify that initial comprehensive antepartum office visit occurred within 16 weeks of the last menstrual period (LMP) (up to and including pregnancies of 16 weeks and 0/7ths days gestation only). Used with HCPCS code Z1032 only. (Reimbursed only once during pregnancy – service limitation of once in nine months.)

Use of this modifier adds $56.63 to reimbursement. Available only to Comprehensive Perinatal Services Program (CPSP) providers. For enrollment information, see Pregnancy: Comprehensive Perinatal Services Program (CPSP) in the appropriate Part 2 manual.

ZQ Not applicable. This is an interim (local) modifier.

Family planning counseling. Certifies that family planning counseling was provided during a routine non-family planning office visit. Limited to female recipients 15 – 44 years of age. Can be reimbursed once per recipient per provider in a 12-month period. (For detailed billing information, see Family Planning in the appropriate Part 2 manual.)

ZS Not applicable. This is an interim (local) modifier.

Professional and technical component

modif app 21


Discontinued and Invalid Modifiers Below is a list of discontinued and invalid modifier codes for use in billing Medic-Cal. Modifiers listed below are no longer acceptable for billing Medic-Cal.

Discontinued/ Invalid Modifier

Discontinuation Date

Modifier Description

21 September 1, 2009 Prolonged evaluation and management services (see Evaluation and Management [E&M] section in the appropriate provider manual on how to bill for prolonged E&M visits)

60 May 1, 2009 Altered surgical field. Use modifier 22.

75 May 1, 2009 Concurrent care, services rendered by more than one physician

AF August 1, 2005 Anesthesia complicated by total body hypothermia above 30 degrees

AG August 1, 2005 Emergency anesthesia (moribund patient)

AN February 1, 2009 Physician assistant service. Replaced by HIPAA compliant modifier U7.

AS February 1, 2009 Physician Assistant serving as first assistant in surgery under an approved supervising physician. Use HIPAA compliant modifier 80 to denote assistant surgeon.

modif app 22





Y1 November 1, 2005 Rental without sales tax (hearing aids)

Y2 November 1, 2005 Purchase or repair without sales tax (hearing aids)

Y6 November 1, 2005 Rental with sales tax (hearing aids)

Y7 November 1, 2005 Purchase, repair, mileage with sales tax (standard item, hearing aids)

YQ November 1, 2005 Certified Nurse Midwife service (when billed by a physician, organized outpatient clinic or hospital outpatient department). Replaced by HIPAA compliant modifier SB.

YR February 1, 2009 Certified Nurse Midwife service (multiple modifiers) (when billed by a physician, organized outpatient clinic or hospital outpatient department). Replaced by HIPAA compliant modifier 99.

YS November 1, 2005 Nurse Practitioner service. Replaced by HIPAA compliant modifier SA.

YT February 1, 2009 Nurse Practitioner service (multiple modifiers). Replaced by HIPAA compliant modifier 99.

YU February 1, 2009 Physician Assistant service (multiple modifiers). Replaced by HIPAA compliant modifier 99.

YV July 1, 2001 AIDS Waiver providers only. Administrative expenses when billed by Computer Media Claims (CMC).

modif app 23





ZA March 1, 2011 Anesthesia procedures complicated by unusual position or surgical field avoidance

ZB

March 1, 2011 Anesthesia (emergency services, healthy patient)

ZC

March 1, 2011 Anesthesia complicated by extracorporeal circulation

ZD

March 1, 2011 Emergency anesthesia (systemic disease)

ZE March 1, 2011 Nurse anesthetist service; elective anesthesia: normal, healthy patient

ZF

March 1, 2011 Anesthesia supervision

ZG

March 1, 2011 Multiple anesthesia modifiers

ZH March 1, 2011 Nurse anesthetist service; anesthesia special circumstances: unusual position/field avoidance

ZI March 1, 2011 Nurse anesthetist service; anesthesia special circumstances: total body hypothermia

ZJ March 1, 2011 Nurse anesthetist service; emergency anesthesia: normal, healthy patient

ZK November 1, 2005 Primary Surgeon. Replaced by HIPAA compliant modifier AG.

ZM November 1, 2010 Supplies and drugs for surgical procedures with other than general anesthesia or no anesthesia. Replaced by HIPAA compliant modifier UA.

ZN November 1, 2010 Supplies and drugs for surgical procedures with general anesthesia. Replaced by HIPAA compliant modifier UB.

ZO March 1, 2011 Nurse anesthetist service; anesthesia special circumstances: extracorporeal circulation

modif app 24





ZP March 1, 2011 Nurse anesthetist service; elective anesthesia: patient with severe systemic disease that is a constant threat to life

ZR March 1, 2011 Nurse anesthetist service; emergency anesthesia: patient with severe systemic disease that is a constant threat to life

ZT March 1, 2011 Nurse anesthetist service; emergency anesthesia: moribund patient who is not expected to survive without the operation

ZU November 1, 2005 Exception modifier to 80 percent reimbursement (medical necessity requires common office procedure to be performed in outpatient setting)

ZV November 1, 2005 Exception modifier to 80 percent reimbursement (non-hospital-compensated physician called from outside to render emergency service)

ZX March 1, 2011 Nurse anesthetist service; emergency or elective anesthesia: patient with severe systemic disease

ZY March 1, 2011 Nurse anesthetist service; elective anesthesia: moribund patient who is not expected to survive without the operation

oth hlth Other Health Coverage (OHC) 1

2 – Other Health Coverage (OHC) July 2011

This section describes the required steps for billing Medi-Cal when a recipient also has OHC, Medicare and Medicare HMO. Refer to the Other Health Coverage (OHC) Codes Chart and Other Health Coverage Guidelines for Billing sections in the Part 1 manual for information about how to determine OHC beneficiary eligibility. Medicare and OHC When a recipient has both Medicare fee-for-service and cost-avoided

OHC, the provider must bill:

1. Medicare for the Medicare-covered services, (do not bill as an automatic crossover claim) and

22.. The OHC carrier

33.. Medi-Cal last. Attach the Medicare Explanation of Medicare

Benefits (EOMB)/Medicare Remittance Notice (MRN) and the OHC Explanation of Benefits (EOB) to the Medi-Cal claim, except Pharmacy providers.

Pharmacy Providers

Pharmacy providers do not submit OHC attachments for electronic or hard copy claim submissions. For more information, see “Pharmacy: Self-Certification for OHC” in this section.

Note: If the OHC is a Medicare supplemental policy through an HMO,

refer the recipient to the HMO. Medicare Part C Recipients Claims for coinsurance and/or deductible claims only for dual-eligible

Village Health Medicare Part C recipients with dates of service from January 1, 2011, to December 31, 2014, must meet the following billing requirements:

• The Remittance Advice submitted with these claims must show “Village Health Medicare Part C” in the Remarks section in the bottom left corner and show the Village Health address and phone number in the upper right corner.

• The claims must show the Village Health Plan Automated Eligibility Verification System carrier code for the other health coverage “S323” in Box 56 of the UB-04 for institutional claims, Box 11c of the CMS-1500 for professional claims or Box 126A for long term care claims on the Payment Request for Long Term Care (25-1).

Claims for services not covered by Medicare Part C may be billed as regular Medi-Cal claims without other special billing requirements.

oth hlth 2


Medical Supply Claims: OHC documentation requirements for providers billing for medical OHC Documentation supplies are simplified. Refer to “Other Health Coverage

Documentation” information in the Medical Supplies section of the appropriate Part 2 manual for information.

Billing Medi-Cal These principles must be followed when billing Medi-Cal after After OHC billing OHC:

• The OHC must be used completely.

• Medi-Cal may be billed for the balance, including OHC copayments, OHC coinsurance and OHC deductibles. Medi-Cal will pay up to the limitations of the Medi-Cal program, less the OHC payment amount, if any.

• Medi-Cal will not pay the balance of a provider’s bill when the

provider has an agreement with the OHC carrier/plan to accept the carrier’s contracted rate as a “payment in full.”

• An Explanation of Benefits (EOB) or denial letter from the OHC

must accompany the Medi-Cal claim, except for Pharmacy providers. Refer to “Pharmacy: Self-Certification for OHC” in this section.

• The amount, if any, paid by the OHC carrier for all items listed on the Medi-Cal claim form must be indicated in the appropriate field on the claim. Providers should not reduce the Charge amount or Total Amount billed because of any OHC payment. Refer to claim form completion instructions in this manual for more information.

OHC EOB or Denial When billing Medi-Cal for any service partially paid or denied by the Letter: Documentation recipient’s OHC, the OHC EOB or denial letter must accompany the Required by Medi-Cal claim and state the following:

• Carrier or carrier representative name and address • Recipient’s name or Social Security Number • Date • Statement of denial, termination or amount paid • Procedure or service rendered • Termination date or date of service

oth hlth 3


When a service or procedure is not a covered benefit of the recipient’s OHC, a copy of the original denial letter or EOB is acceptable for the same recipient and service for a period of a year from the date of the original EOB or denial letter.

A dated statement of non-covered benefits from the carrier is also

acceptable if it matches the insurance name and address and the recipient’s name and address.

It is the provider’s responsibility to obtain a new EOB or denial letter at

the end of the one-year period. Claims not accompanied by proper documentation will be denied.

Pharmacy and Medical Supply Providers Pharmacy providers do not include OHC attachments with pharmacy claims because the entry of the OHC code on the claim self-certifies for the OHC requirement. Pharmacy providers must, however, be able to retrieve information received from a recipient’s OHC carrier. Refer to “Pharmacy: Self-Certification for OHC” in this section. Providers billing for medical supplies may refer to “Other Health Coverage Documentation” information in the Medical Supplies section of the appropriate Part 2 manual for important OHC billing information.

OHC Cost-Sharing Providers are prohibited from billing Medi-Cal recipients, or individuals

acting on their behalf, for any amounts other than the Medi-Cal copayment or Share of Cost (SOC).

Therefore, if the recipient’s OHC requires a copayment, coinsurance, deductible or other cost-sharing, the provider is not permitted to bill the recipient. If the provider bills the OHC and the OHC denies or reduces payment because of its cost-sharing requirements, the provider may then bill Medi-Cal. Medi-Cal will adjudicate the claim, deducting any OHC payment amounts.

When to Bill OHC Refer to the chart in the Other Health Coverage (OHC) Codes Chart

section of the Part 1 manual to determine when to bill OHC.

oth hlth 4


Delayed Insurance If a response from the OHC carrier is not received within 90 days of Response the provider’s billing date, providers may bill Medi-Cal. A copy of the

completed and dated insurance claim form must accompany the Medi-Cal claim. State “90-day response delay” on the attachment.

Medi-Cal Remittance OHC billing information is included on the Medi-Cal Remittance Advice Details (RAD) Advice Details (RAD) when a claim is denied because the provider did

not include proof of insurance billing with the Medi-Cal claim.

If available, the OHC information provided will include the insurer’s name and billing address and the policyholder’s Social Security Number. This information helps providers billing OHC. For more information, refer to the Remittance Advice Details (RAD) examples and Remittance Advice Details (RAD): Payments and Claim Status sections in this manual. For general RAD information, refer to the Remittance Advice Details (RAD) and Medi-Cal Financial Summary section in the Part 1 manual.

oth hlth 5

2 – Other Health Coverage (OHC) November 2009

HMO Denial The Department of Health Care Services (DHCS) Fiscal Letters Intermediary (FI) often receives HMO denial letters containing the statement: “HMO eligible, but services were not rendered by an HMO facility/provider; therefore, patient is not eligible for HMO benefits.” This is not an acceptable denial letter because the recipient did not exhaust the HMO coverage.

In order to establish Medi-Cal liability to pay claims for a recipient with HMO coverage, the provider must obtain a denial letter or EOB that clearly states one of the following:

• The recipient’s HMO coverage has been exhausted, or

• The specific service is not a benefit of the HMO.

Kaiser Denial Providers billing Medi-Cal for Kaiser non-covered services must attach Letters a specific denial letter from Kaiser (see sample on a following page).

Denial reasons 2, 5 and 8 are not acceptable.

Although the directive in item 8 of the Kaiser denial letter states that providers should bill the patient directly, providers are reminded that State law prohibits them from billing Medi-Cal recipients.

Note: Kaiser facilities billing Medi-Cal for services that are not benefits

of Kaiser must also include a statement with the claim containing the required denial information. A rubber stamp is acceptable only if it provides spaces to fill in the required information, directly relating it to the claim form submitted.

oth hlth 6


Sample Kaiser Denial Letter.

On Kaiser Letterhead

Provider Name and Address: Date: Kaiser Plan No.: RE: DATE(S) OF SERVICE: TYPE OF SERVICE: We are unable to consider payment for the above service you rendered for the following reason(s): ___ 1. The person named above was not covered by our Plan at the time of service. ___ 2. Our members are not covered for non-emergency services obtained from non-Plan providers. All services except

certain emergency care must be obtained from Plan facilities and physicians. ___ 3. Our members are not covered for the type of service specified above. This service is a contractual exclusion of our

plan. ___ 4. The person named above is not covered by our prescription drug benefit. ___ 5. Prescriptions purchased at non-Plan pharmacies are not covered by our prescription benefit. ___ 6. The item purchased is not covered by our prescription drug benefit. ___ 7. The person named above does not have coverage for eyeglasses or contact lenses. ___ 8. Please bill the patient directly. Kaiser Foundation Health Plan will consider reimbursement only for emergency care

and only when our member requests reimbursement through our Out-of-Plan Claims procedure. ___ 9. We are unable to identify the above person as a member of our program. ___ 10. Other: _______________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

KAISER FOUNDATION HEALTH PLAN, INC. SERVICE REPRESENTATIVE

oth hlth 7

2 – Other Health Coverage (OHC) November 2009

Prescription Drugs Pharmacy providers are required to bill OHC prior to billing Medi-Cal for Long Term for prescription drugs dispensed to recipients in Long Term Care Care Recipients: (LTC) facilities. The provider may request that Scope of Coverage COV Code “P” (COV) code “P” be removed from the recipient’s eligibility record if:

• The recipient has no insurance. • The recipient’s OHC has lapsed. • The OHC does not cover pharmacy services dispensed in an

LTC facility. • The OHC is limited to specific pharmacy providers who cannot

meet facility licensing standards.

Follow existing Medi-Cal billing requirements regarding OHC (submit claims to the FI with OHC denial letters attached) until the eligibility verification message does not reflect COV code “P.” Pharmacy Providers A sample Pharmacy Long Term Care Insurance Referral form with the address for the Health Insurance Section/LTC Unit is found at the end of this section. Copy this form as needed. Additional supplies are not available.

Medicare Drug Coverage Under the provisions of the Medicare Catastrophic Coverage Act, for NF-B Patients – Medicare Part A covers up to 150 days of Nursing Facility Level B Part A Benefits for (NF-B) services per calendar year. Some residents who are Long Term Care eligible for both Medicare and Medi-Cal have been relocated in order

to use this Medicare benefit. Payment for NF-B Resident Pharmacy providers should first inquire about the actual location of Prescription Drug Services the NF-B resident within the facility before rendering Medi-Cal

prescription drug services.

• If residents have Medicare coverage, Pharmacy providers must bill the facility for the drug services since Medicare reimburses the Nursing Facility with payments for all services including drug services. Do not bill Medi-Cal.

• If residents do not have Medicare coverage, Pharmacy providers may bill Medi-Cal separately for prescription drugs.

oth hlth 8

2 – Other Health Coverage (OHC) October 2007

Pharmacy: Self-Certification Pharmacy providers may complete self-certification for OHC for OHC electronically or by using the Pharmacy Claim Form (30-1). Pharmacy

providers do not need to submit an OHC attachment. However, providers must be able to readily retrieve proof of claim submission and payment if collected from the other payer(s). Note: The ability to self-certify for Other Health Coverage on

pharmacy claims does not apply to medical supplies, with the exception of diabetic supplies.

Electronic Self-Certification OHC will be self-certified for providers submitting electronic claims if a

valid OHC code is entered. If an invalid code is entered for a recipient with OHC, the claim will be denied. Valid OHC codes can be found in

the Medi-Cal POS NCPDP Pharmacy Transaction Specifications guide available on the Medi-Cal Web site (www.medi-cal.ca.gov). To access the guide, click “Technical Specs” under “Provider Resources,” then click the “Medi-Cal POS NCPDP Pharmacy Transaction Specifications, Third Party Vendors” link. Field number 308 contains the most current approved values. Search for “308” to find all instances of this field. Questions regarding the placement of these codes in claims produced by pharmacy software programs should be directed to the software vendor.

Claim Form Self-Certification OHC will be self-certified for providers submitting paper claims if the

Other Coverage Paid field (Box 24) and the Other Coverage Code field (Box 25) are completed as instructed in the Pharmacy Claim Form (30-1) Completion section of the Part 2 Pharmacy manual.

Long Term Care Recipients: If the recipient’s insurance does not cover LTC services, the policy COV Code “L” has lapsed or the benefits have been exhausted, COV code “L” can be

removed from the recipient’s eligibility file. To request removal of an incorrect COV code, send a copy of the

OHC denial letter or EOB, along with a completed Long Term Care Insurance Referral form, to the Department of Health Care Services (DHCS) Health Insurance Section/LTC Unit. Follow existing Medi-Cal billing requirements regarding OHC (that is, submit claims with the OHC denial letters attached) until the eligibility verification message does not reflect COV code “L.”

Long Term Care Providers A sample Long Term Care Insurance Referral form with the address

for the Health Insurance Section/LTC Unit is found at the end of this section. Copy this form as needed. Additional supplies are not available.

oth hlth cpt Other Health Coverage (OHC): CPT-4 and HCPCS Codes 1

2 – Other Health Coverage (OHC): CPT-4 and HCPCS Codes June 2010

This chart lists service codes that may be billed directly to Medi-Cal at the provider’s option, even if the recipient has OHC coverage. Refer to Other Health Coverage (OHC) in this manual for specific instructions.

Recipients With OHC Coverage

Codes Description (alphabetical order) When to Bill Medi-Cal Directly

S5102 *, H2000, T1023 Adult Day Health Care HCPCS Level II Codes

May be billed directly to Medi-Cal even though the recipient has OHC.

G0154, G0156, S5130, S5170, S9470, T2003, T2022, T2025, T2026, T2028, T2029

90806, 90846, 90847

AIDS Waiver Program HCPCS Level II Codes

CPT-4 Codes


Z5400 – Z5470, Z5499 CCS (California Children’s Services) HCPCS Level III Codes (OHC Code “9”)


59840, 59841, 59850, 59851, 59852

Elective abortions for CHAMPUS-covered recipients only CPT-4 Codes (OHC Code “C”)


Z9700 – Z9703 Expanded Access to Primary Care (EAPC) Program


G9012, H0045, S5111, S5160, S5161, S5165, S9122, S9123, S9124, T1005, T1016, T1019, T2017, T2033, T2035, T2038

Home and Community-Based Services (HCBS) HCPCS Level II Codes


* S5102 requires a TAR before a claim may be submitted

oth hlth cpt 2

2 – Other Health Coverage (OHC): CPT-4 and HCPCS Codes May 2006


658 Hospice Care Room and Board May be billed directly to Medi-Cal even though the recipient has OHC.

Z8550 – Z8599 Multipurpose Senior Services Program (MSSP)


X0200 – X0222, X0400 – X0416

Non-Emergency Medical Transportation HCPCS Level III Codes


oth hlth cpt 3

2 – Other Health Coverage (OHC): CPT-4 and HCPCS Codes August 2009

Recipients With OHC Coverage Through an HMO The following services may be billed directly to Medi-Cal, unless the recipient has OHC coverage through an HMO. HMO benefits must be used first.


Z5802, Z5804, Z5806, Z5814, Z5816, Z5820, Z5822, Z5832, Z5834, Z5836, Z5838, Z5840, Z5999

EPSDT Supplemental Services HCPCS Level III Codes

HMO benefits must be used first.

90378, 90585, 90646, 90655 – 90658, 90691 – 90693, 90702, 90703, 90705, 90707, 90712, 90713 – 90727, 90733

Immunization Injection Codes CPT-4 Codes


Z1032, Z1034, Z1036, Z1038, Z6200 – Z6500

Pregnancy Care HCPCS Level III Codes (Physicians’ services only)


59000, 59020, 59400, 59510, 59610, 59618

Pregnancy Care CPT-4 Codes (Physicians’ services only)


96110, 99381, 99382, 99383, 99384, 99391, 99392, 99393, 99394, 99461

Preventive Pediatric CPT-4 Codes


Provider Billing after Beneficiary prov bil Reimbursement (Conlan v. Shewry) 1

2 – Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) January 2007

This section includes claims processing guidelines for providers submitting claims covered by the terms of the Conlan v. Shewry court ordered Beneficiary Reimbursement process. These guidelines apply to all Medi-Cal provider types. Background The Beneficiary Reimbursement process provides that eligible

beneficiaries who paid out-of-pocket for medical or dental care either during the three month retro period prior to the month they applied for Medi-Cal eligibility, or while waiting for their Medi-Cal applications to be approved, or after receiving their Medi-Cal card are entitled to be reimbursed for out-of-pocket monies they paid to a provider for Medi-Cal covered services. In general, beneficiaries are notified by letter that they may qualify for reimbursement under the terms of the court order.

Beneficiary Service Center A Beneficiary Service Center (BSC) was established to work with both

providers and beneficiaries to process Beneficiary Reimbursement claims. Beneficiaries may contact the center to obtain information and forms for requesting reimbursement. The BSC address and telephone number are as follows:

Beneficiary Service Center P.O. Box 138008 Sacramento, CA 95813-8008 (916) 403-2007 BSC Responsibilities BSC responsibilities include the following:

• Verifying beneficiary Medi-Cal eligibility

• Verifying the service was a Medi-Cal covered benefit on the date of service

• Evaluating supporting medical expense documentation provided by the beneficiary

• Reviewing rendered services for medical necessity

• Determining whether Medi-Cal payment was previously made

• Verifying that the provider reimbursed the beneficiary

• Maintaining documentation for each case

prov bil 2

2 – Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) December 2009

Provider Notification of If a beneficiary’s request for reimbursement is validated by the BSC, Beneficiary Request a letter of request for beneficiary reimbursement is sent to the for Reimbursement provider. The letter, Letter 08, must be submitted with the provider’s

claim for reimbursement. Provider Responsibility Providers, upon receipt of the beneficiary reimbursement letter

(Letter 08), are expected to reimburse beneficiaries for monies the beneficiary paid to the provider for a Medi-Cal covered service, then bill Medi-Cal for the same service. Claims will be denied if the beneficiary has not been reimbursed. In accordance with the court order to obtain prompt reimbursement to the beneficiary, providers that do not comply with the request for beneficiary reimbursement are subject, when appropriate, to recoupment action by the Department of Health Care Services (DHCS) of all monies paid to the provider by the beneficiary for Medi-Cal covered services.

Claim Submission Providers must, within 60 days of the date on the beneficiary

reimbursement letter, submit claims to Medi-Cal as follows:

• Submit an original hard copy claim solely for services mentioned in the beneficiary reimbursement letter

• Enter delay reason code 10 in the appropriate claim field (refer to instructions in the Claim Submission and Timeliness Overview section of the Part 1 manual)

• Attach the beneficiary reimbursement letter

• Attach any additional required Medi-Cal documentation The original claim, beneficiary reimbursement letter and supporting documentation must be submitted to the DHCS Fiscal Intermediary (FI) at the following address:

HP Enterprise Services Beneficiary Service Center Claims Unit P.O. Box 138008 Sacramento, CA 95813-8008

No electronic claim submission is allowed. Because the BSC determines medical necessity, no Treatment Authorization Request (TAR) is required. The six-month billing limit will be modified for these claims.

prov bil 3

2 – Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) December 2009

APPEAL PROCESS OVERVIEW Filing an Appeal Appeals filed on claims resulting from a beneficiary request for

reimbursement will follow the same guidelines referenced in the Appeal Form Completion section of this manual. Refer to the Appeal Form Completion section of the Part 2 manual for Appeal Form (90-1) completion instructions.

Timeliness: Providers must submit an Appeal Form in writing within 90 days of the 90-Day Deadline action/inaction precipitating the complaint. Failure to submit an appeal

within this 90-day time period will result in the appeal being denied. See California Code of Regulations, Title 22, Section 51015.

Where to Submit Appeals Providers should mail appeals to the FI at the following address: HP Enterprise Services Beneficiary Service Center Claims Unit P. O. Box 138008 Sacramento, CA 95813-8008 Claims Inquiry Forms (CIFs) Claims Inquiry Forms (CIFs) will not be accepted on providers’ claims

resulting from a beneficiary request for reimbursement. For reconsideration of a denied claim, an appeal must be filed.

prov bil 4

2 – Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) January 2007

Reimbursement The reimbursement rate is the rate on file for the date of service, or if one is not listed, the current rate.

Enrollment Requirement To be reimbursed, the provider must have been enrolled as a

Medi-Cal provider on the date of service. Per the instructions on the beneficiary reimbursement letter, providers should contact the Medi-Cal Provider Enrollment Branch if any of the following conditions apply:

• The provider was not a Medi-Cal provider on the date of

service, but wants to enroll now.

• The provider is a Medi-Cal provider now, but was not on the date of service and needs retroactive eligibility.

• The provider was not a Medi-Cal provider on the date of service, but wants to temporarily enroll retroactively in Medi-Cal in order to bill for the Beneficiary Reimbursement Process claims.

Claims for Medi-Cal Providers must verify eligibility for Medi-Cal managed care Managed Care Beneficiaries beneficiaries and seek prior authorization from the Medi-Cal managed

care plan before rendering non-emergency services. Providers risk denials of claims for services if they are not members of the provider network of the managed care plan in which the beneficiary is enrolled.

remit adv Remittance Advice Details (RAD) 1

2 – Remittance Advice Details (RAD) January 2003

The Remittance Advice Details (RAD) is designed for line-by-line reconciliation of transactions. Reconciliation of the RAD to providers’ records will help determine which claims are paid, denied or not yet adjudicated. Medi-Cal-only claims appear first, followed by Medicare/Medi-Cal crossover claims in this sequence: adjustments, approves, denies, suspends and Accounts Receivable (A/R) transactions. Refer to the Remittance Advice Details (RAD) examples section in this manual for an explanation of form items and completed sample RADs. Adjustments An adjustment reprocesses a claim with corrected information and

appears on the RAD as two lines. Line one shows the new Claim Control Number (CCN) and the amount the claim should have paid. Line two shows the original CCN and reverses the original payments.

In Figure 3 of the Remittance Advice Details (RAD) examples section

of this manual, a 572 adjustment is being processed to recover the original payment of $8 and to repay the claim at $6. The net transaction amount is a recoupment of $2. Adjustment code 572 appears in the RAD message column indicating: “Provider initiated – Adjustment as a result of a prior overpayment.”

Two-Line Entry An exception to the two-line entry for an adjustment occurs when a Exception warrant is returned by the provider because of an incorrect payment

and the provider is requesting reimbursement for the correct claims. A 599 adjustment is processed for the correct claims and appears on the RAD as a one-line adjustment. The negative side of the adjustment does not appear on the RAD because the money has already been returned.

Voids A void adjustment appears on the RAD as a single line and has

negative (-) amounts. A void recovers the original payment without reprocessing the claim for payment.

CIFs for POS and Pharmacy providers should not submit a hard copy Claims Inquiry RTIP Claims: Form (CIF) to reverse a claim originally submitted over the Point of

Pharmacy Providers Service (POS) network or through the Real-Time Internet Pharmacy (RTIP) claim submission system unless they are returning an overpayment. Instead, they should reverse the claim over the POS network or through the RTIP system, then resubmit a corrected claim if necessary. Information about reversing claims over the POS network is found in the Pharmacy Claim Submission section of the POS Device User Guide. Providers also may call the POS/Internet Help Desk at 1-800-427-1295 or contact their software vendor.

remit adv 2

2 – Remittance Advice Details (RAD) November 2009

Approves Approved claims may show:

• Claims reimbursed as submitted • Claims reduced for payment • Claims previously denied but paid as a result of a

provider-initiated CIF or due to resubmitted claims In Figure 4 of the Remittance Advice Details (RAD) examples section

of this manual, reason code 401 appears in the RAD message column indicating: "Payment adjusted to maximum allowable."

Denies Denied claims may occur if any one of the following conditions exist:

• Claim information cannot be validated by the DHCS Fiscal Intermediary (FI)

• The billed service is not a program benefit • The line item fails the edit/audit process • The provider fails to return a Resubmission Turnaround

Document (RTD) within the 60-day period

Services denied on the RAD appear on one line. A denied claim may be reconsidered for payment if errors were made in submitting or processing the original claim.

In Figure 5 of the Remittance Advice Details (RAD) examples section of this manual, denial reason code 009 appears in the RAD message column indicating: “This service is not a covered benefit of the Medi-Cal program.”

remit adv 3

2 – Remittance Advice Details (RAD) March 2011

CIF Process The denied message on the RAD is the only record of a claim denial. If a provider feels a claim has been inappropriately denied, the claim may be reconsidered for payment. The provider must request

reconsideration through the claims inquiry process, unless the claim is denied due to a National Correct Coding Initiative (NCCI) edit. Then the claim must be appealed. The CIF must be properly completed

and must include necessary corrected or additional claim information (such as proof of Medicare non-eligibility or an approved Treatment Authorization Request (TAR) that was not submitted with the original claim and resulted in a denial. To expedite the resubmittal process, attach a clear photocopy of the corrected original claim or retype the claim. For complete CIF instructions, refer to the CIF Completion section in this manual.

Denied claims resubmitted and approved for payment by the FI Claims Research Department will appear on the RAD under the heading “Approve.” These claims will show a new Claim Control Number.

Suspends Claims requiring manual review or awaiting the return of a

Resubmission Turnaround Document (RTD) will temporarily suspend and appear on the RAD with a “suspend” message code. After a suspended claim has been in the computer system for more than 30 days, it will appear on the RAD until payment or denial. Suspended claims are in the processing cycle and will be adjudicated. Providers should not submit Claims Inquiry Forms (CIFs) for claims listed as “suspends” on the most recent RAD.

Types of Claim In some instances, claims suspend due to conditions that cannot be Suspensions resolved by additional input from the provider (such as, eligibility

mismatches, claims requiring manual pricing). These conditions will be resolved by the FI, and RTDs will not be generated. If a claim suspends due to an error that can be corrected by the provider, an RTD will be generated.

In Figure 6 of the Remittance Advice Details (RAD) examples section

of this manual, a suspended claim is shown on one line. Reason code 601 appears in the RAD message column indicating: “Pending return of Resubmission Turnaround Documents.”

remit adv 4

2 – Remittance Advice Details (RAD) November 2009

Accounts Receivable The RAD may also reflect Accounts Receivable (A/R) transactions Transactions when it is necessary to recover funds from a provider or to pay funds

to a provider. The FI’s Accounts Receivable system is used in financial transactions pertaining to:

• Recoupment of interim payments • Withholds against payments to providers according to State

instructions • Payments to providers according to State instructions

Accounts Receivable transactions appear last on a RAD as follows:

• They are identified in the FI’s system by a 10-digit A/R transaction number, such as “1234567890”.

• Amounts can be either positive (+) or negative (-) figures that correspond to the increase or decrease in the amount of the warrant.

• A/R transaction codes appear at the bottom of the page in the RAD message column and begin with the number “7.”

In Figure 7 of the Remittance Advice Details (RAD) examples section of this manual, the A/R transaction appears as:

730 Amount withheld as a result of claims overpayment. No Payment Advice If there are no claims being paid or if a payment is being applied to a

negative adjustment or Accounts Receivable (A/R), a No Payment Advice is issued instead of a warrant.

Remittance Advice Details (RAD) remit ex op Examples: Outpatient Services 1

2 – Remittance Advice Details (RAD) Examples: Outpatient Services Outpatient Services August 2000

This section explains the Remittance Advice Details (RAD) fields and shows examples of the various types of reimbursement data received during a payment period. Refer to the Remittance Advice Details (RAD) section in this manual for details about the RAD. RAD codes appear in the far right column for each claim line and their full explanation appears at the bottom of the RAD. The RAD includes a maximum of three denial code messages. Codes with the prefix “9” indicate a free-form error message, which allows Medi-Cal claims examiners to return unique free-form messages that more accurately describe claim submittal errors and denial reasons.

remit ex op 2

2 – Remittance Advice Details (RAD) Examples: Outpatient Services Outpatient Services 400 January 2008

CA MEDI-CAL REMITTANCE ADVICE

DETAILS

TO: ABC PROVIDER P.O. BOX 999 ANYTOWN, CA 99999-1234 REFER TO PROVIDER MANUAL FOR DEFINITION OF RAD CODES

PROVIDER NUMBER 0123456789

CLAIM TYPE OUTPATIENT

WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages

RECIPIENT NAME RECIPIENT MEDI-CAL ID NO.

CLAIM CONTROL NUMBER

SERVICE DATES PROC CODE

PATIENT CONTROL NUMBER

QTY TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY APPROVES (RECONCILE TO FINANCIAL SUMMARY) SMITH DAVID

90000000A95001

5079410416401

031707 031707 031707 031707 031707 031707 031707 031707 031707 031707

031707 031707 031707 031707 031707 031707 031707 031707 031707 031707

XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX

39830

20

1730.00 442.80 282.20 28.90

173.80 24.50

126.00 142.00

2222.00 655.00

310.00

60.00

1420.00 442.80 282.20 28.90

173.80 24.50

126.00 142.00

2222.00 595.00

0417

*****TOTALS FOR APPROVES 10 5827.20 370.00 5457.20 0.57 3110.60 0417 3110.60 AMT PAID DENIES (DO NOT RECONCILE TO FINANCIAL SUMMARY)

DAVIS MARY 90000000A95001 5030412005101 011107 011107 011107 011107 011107 011107 011107

011107 011107 011107 011107 011107 011107 011107

XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX

39186 598.10 1094.00

85.40 213.10 18.40 10.60 30.90

TOTALS NUMBER OF DENIES 7 2050.50 0036 SUSPENDS (DO NOT RECONCILE TO FINANCIAL SUMMARY) JOHNSON M 90000000A95001

5030412006701 PAT LIAB

090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 932.00

090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 090907 OTH

XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX XXXXX COVG

37089 0.00

180 SALES

8520.00 9999.99 5403.80 788.05 175.35

4509.20 633.60 373.10 142.50 806.40 711.00 161.00

1304.41 2963.00 282.00

TX 0.00

0602

TOTALS NUMBER OF SUSPENDS 15 36773.40

EXPLANATION OF DENIALS/ADJUSTMENT CODES 0417 BILLED AMOUNT IS CUTBACK TO ALLOWED PER THE ACCOMODATION RATE FILE OR TO DISALLOW PAYMENT FOR DAY OF DISCHARGE/DEATH 0036 RTD WAS EITHER NOT RETURNED OR WAS RETURNED UNCORRECTED; THEREFORE YOUR CLAIM IS FORMALLY DENIED 0602 PENDING ADJUDICATION.

OHC CARRIER NAME AND ADDRESS NO49 123 NATIONAL LIFE 100 MAIN STREET ANYTOWN MN 99999

Figure 1. Completed Sample Outpatient Remittance Advice Details (RAD). Actual size is 8½ x 11 inches.

8 9

18 19 20 16 21 22

12 13 7

6 4 3

1 2

14

15 17

23

5 10 11

remit ex op 3

2 – Remittance Advice Details (RAD) Examples: Outpatient Services Outpatient Services 334 August 2002

Explanation of The following items refer to the corresponding circled numbers on the Form Items RAD. (See Figure 2 for RAD items specific to crossover payments.)

Item Description

1. RECIPIENT NAME. Listed last name first.

2. RECIPIENT MEDI-CAL I.D. NO. The recipient Medi-Cal identification number.

3. CLAIM CONTROL NUMBER. A unique 13-digit number assigned by EDS to track each claim line or CIF. See

Figure 2 on a following page for a detailed description. This number will appear on the RAD accompanying a warrant. Use this number when submitting a Claims Inquiry Form (CIF) or Appeal Form (90-1) to request adjustments to paid claims or reconsideration of denied claims. Refer to the Claim Submission and Timeliness Overview section in the Part 1 manual for an illustration of a Claim Control Number (CCN).

4. SERVICE DATES. Date(s) that service was rendered to a

recipient.

5. PROC. CODE. HCPCS or CPT-4 procedure code.

6. MEDICAL RECORD NUMBER. Provider’s internal reference number for a patient.

7. QTY. Quantity billed.

8. TOTAL CHARGES. Corresponds to the gross amount billed on the claim.

9. NON-COVERED. Total of non-allowed charges.

remit ex op 4

2 – Remittance Advice Details (RAD) Examples: Outpatient Services Outpatient Services 334 August 2002

Item Description

10. PAYABLE CHARGES. Allowable amount for the line item billed (total charges less non-covered charges).

11. RATE. Reimbursement rate will be shown as a percentage of payable charges.

12. PAID AMOUNT. Amount paid. When reconciling the amount paid to the warrant amount, add the line amounts, not the claim summary amount. Payment appears on the warrant on the same page where the line amount appears.

13. RAD CODE. Denial code that appears beside each claim line billed.

14. RAD MESSAGE. Code and abbreviated message appear on the first line. If the claim is an adjustment or a denial due to duplicate billing, the warrant number of the original claim appears on the second line.

15. DENIAL CODES AND MESSAGES. Denial codes with their full explanation appear at the bottom of the RAD under a summary header.

16. EDS SEQUENCE NUMBER. An eight-digit sequence number that appears on the RAD and warrant. This number serves as an additional tracking device on the warrant along with the State Controller’s Office (SCO’s) warrant number.

remit ex op 5


Item Description 17. OTHER HEALTH COVERAGE BILLING MESSAGE. This

includes name and address of recipient’s insurance carrier and the policyholder’s SSN. This information is included on the RAD when the claim has been denied because proof of Other Health Coverage billing was required and did not accompany the claim. (RAD code 657 is used to indicate this denial.)

18. PROVIDER NUMBER. A National Provider Identifier (NPI). 19. CLAIM TYPE. The type of claim submitted for

reimbursement. 20. WARRANT NO. An eight-digit number assigned by the SCO. 21. DATE. SCO issue date of the RAD. 22. PAGE. Number of pages of the RAD. 23. PATIENT LIABILITY/OTHER COVERAGE. A patient’s copay,

coinsurance, Share of Cost or Other Health Coverage. Any sales tax amount included in the payment also appears in this area. On crossover claims, the notation “sales tax included” appears; however, a dollar amount is not specified.

Note: Sales tax applies to Allied Health, Medical Services,

Outpatient, Pharmacy and Vision Care providers.

remit ex op 6



DETAILS



CLAIM TYPE MCARE CROSSOVER

WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages

RECIPIENT NAME RECIPIENT MEDI-CAL ID

NO.


SERVICE DATES ACCOM/PROC CODE


DAYS MEDICARE ALLOWED

MEDI-CAL ALLOWED

COMPUTED MEDICARE AMOUNT

PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY

APPROVES (RECONCILE TO FINANCIAL SUMMARY) DAVIS JANE 90000000A95001 5079171505699 060107 061107 039634 716.00 0469 BLOOD DEDUCT 0.00 DEDUCTIBLE 716.00 COINSUR 0.00 CUTBACK 716.00 SALES TAX INCL DENIES (DO NOT RECONCILE TO FINANCIAL SUMMARY) JOHNSON MA 90000000A95001 5006170703899 040307 040307 039305 696.00 0036 BLOOD DEDUCT 0.00 DEDUCTIBLE 696.00 COINSUR 0.00 CUTBACK 696.00 SUSPENDS (DO NOT RECONCILE TO FINANCIAL SUMMARY) JONES DAVID 90000000A95001 5033172401899 041607 042307 039357 696.00 0602 BLOOD DEDUCT 0.00 DEDUCTIBLE 696.00 COINSUR 0.00 CUTBACK 696.00

EXPLANATION OF DENIALS/ADJUSTMENT CODES 0469 PAYMENT REDUCED TO ZERO AS MEDI-CAL’S MAX REIMBURSEMENT MAY NOT EXCEED MEDICARE’S PAYMENT. CUTBACK IS IN NON-COVERED COLUMN. 0036 RTD WAS EITHER NOT RETURNED OR WAS RETURNED UNCORRECTED; THEREFORE YOUR CLAIM IS FORMALLY DENIED. 0602 PENDING ADJUDICATION.

Figure 2. Completed Sample Medicare Crossover Remittance Advice Details (RAD).

Actual form is 8½ x 11 inches. Crossover Payments The following items appear on RADs for crossover payments only.

(See Figure 2 above.) Refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual for additional information.

Item Description 5. ACCOMMODATION/PROCEDURE CODE. CPT-4 or HCPCS

procedure code. 8. MEDICARE ALLOWED. Amount allowed by Medicare. 9. MEDI-CAL ALLOWED. Amount allowed by Medi-Cal or the

amount allowed by Medicare, whichever is less. 10. COMPUTED MEDICARE AMOUNT. Amount paid by

Medicare.

5 8 9 10 6

remit ex op 7


Claim Status The following figures illustrate how adjudicated claims appear on the RAD. Refer to the Remittance Advice Details (RAD) section in this manual for additional information about these RAD codes.


DETAILS




WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages


NO.




QTY TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY ADJUSTMENTS (RECONCILE TO FINANCIAL SUMMARY) SMITH JO 90000000A95001 5079171505699 031007 031007 XXXXX 98892 31 6.00 6.00 6.00 0572 -8.00 -8.00 -8.00 0572 ***** TOTALS FOR ADJUSTMENTS -2.00 -2.00 -2.00

Figure 3. Adjustment Code 572.



WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages

RECIPIENT NAME

RECIPIENT MEDI-CAL ID NO.




QTY TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY

APPROVES (RECONCILE TO FINANCIAL SUMMARY) SMITH JO 90000000A95001 5079171505699 061407 061407 XXXXX 13938 0001 832.00 793.00 39.00 1.00 39.00 0401 ***** TOTALS FOR APPPROVES 832.00 793.00 39.00 39.00 39.00 AMT PAID

Figure 4. Approve Reason Code 401.



WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages


NO.




QTY TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY

DENIES (DO NOT RECONCILE TO FINANCIAL SUMMARY) JONES JOHN 90000000A95001 5079171505699 041107 041107 XXXXX 13654 1163.15 0009 DAVIS DAVE 90000000A95001 5079173305699 061507 061507 XXXXX 14197 8.00 0037 ***** TOTALS NUMBER OF DENIES 1171.15

Figure 5. Denial Reason Code 009.

remit ex op 8



DETAILS




WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages


NO.




QTY TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY SUSPENDS (DO NOT RECONCILE TO FINANCIAL SUMMARY) SMITH JO 90000000A95001 5079171505698

5079171505699 041907 041907

041907 041907

XXXXX XXXXX

13715 13715

0001 0001 TOTAL

95.00 2567.00 2662.00

0601 0601

DAVIS MARY 90000000A95001 5079171505700 PAT LIAB

052807 932.00

052807 OTH

XXXXX COVG

13564 0.00

0001

314.00 0601

TOTALSNUMBER OF SUSPENDS 0003 2976.00

Figure 6. Suspended Reason Code 601.



WARRANT NO 39248026

EDS SEQ. NO. 99999999

DATE 01/01/08

PAGE: 1 of 1 pages


NO.


SERVICE DATES ACCOM CODE


DAYS OR

VISITS

TOTAL CHARGES

NON COVERED

PAYABLE CHARGES

RATE PAID AMOUNT

RAD CODE

FROM TO

MMDDYY MMDDYY

A/R TRANS. NO. 90000000A95001 DO NOT RECONCILE TO FINANCIAL SUMMARY 156.76 0730

Figure 7. Accounts Receivable (A/R) Transaction Code 730.

Remittance Advice Details (RAD): remit pay Payments and Claim Status 1

2 – Remittance Advice Details (RAD): Payments and Claim Status November 2007

This section contains information to assist providers in reconciling payment problems. Overpayments When overpayments by the Department of Health Care Services

(DHCS) are noted on Remittance Advice Details (RAD), providers can use one of the following three options to correct the error.

Option 1: Issuing a 1. Providers may prepare a check payable to the "Department of Personal Check Health Care Services” for the total amount overpaid. The provider

number should be included on the face of the check. Providers must not refund more than the amount paid.

2. Providers should attach to the check a photocopy of the RAD on

which the claims are listed and underline each claim involved so adjustments can be made to the claims history file.

3. Providers should send a check and copy of the RAD to:

Attn: Accounting Section Department of Health Care Services MS 1101 1501 Capitol Avenue, Suite 71-2048 P.O. Box 997413 Sacramento, CA 95899-7413

remit pay 2

2 – Remittance Advice Details (RAD): Payments and Claim Status December 2009

Option 2: Submitting a CIF 1. Providers may complete a Claims Inquiry Form (CIF), and request an adjustment. An explanation of the nature of the request should be included.

2. Providers should attach to the completed CIF a copy of the RAD on

which the claims are listed and underline each claim involved so adjustments can be made to the claims history file.

3. Providers should submit the CIF and a copy of the RAD to the DHCS Fiscal Intermediary (FI) at the following address:


Overpayments are recovered on subsequent payment periods, or checkwrites, and appear as negative adjustments on the RAD until they are completely recovered. Refer to the CIF Completion section in this manual for additional information.

Option 3: Returning Providers may return a warrant to the State Controller’s Office (SCO) a Warrant by following the instructions on the back of the warrant. Providers

should include specific information about each claim that appears on the RAD.

Returned Drugs Pharmacy providers may, to the extent permitted by law, accept the in Nursing Facilities return of unopened/unused drugs that were dispensed to Medi-Cal

patients in nursing facilities. The Medi-Cal program can be refunded for these drugs by following one of the claim overpayment options described in this section.

Questions regarding overpayment corrections may be directed to the Telephone Service Center (TSC) at 1-800-541-5555.

remit pay 3

2 – Remittance Advice Details (RAD): Payments and Claim Status March 2011

Underpayments Providers may request an adjustment for underpayments by submitting a Claims Inquiry Form (CIF). Refer to the CIF Completion section in this manual for instructions.

No Record of If a claim was submitted and does not appear on a RAD within 45 Claim days, providers may use a CIF as a tracer. If the tracer response

indicates no record of the claim, providers must file an appeal. Providers should attach the tracer response to the appeal and send a copy of the claim to the FI to have it reconsidered. Refer to the CIF Completion section in this manual for more information about tracers. Refer to the Appeal Process Overview section in the Part 1 manual for information about appeals.

Note: Providers also may rebill using an original claim form if the

service date is within the six-month billing limit. Suspended Claims Providers should take no action on suspended claims, which require

manual review by the FI. After approximately 30 days, a suspended claim should appear as a payment or denial on the RAD.

Reconsideration of Providers may request reconsideration of denied claims by submitting Denied Claims a CIF. Refer to the CIF Completion section in this manual for additional

information.

Exception: CIFs may not be used to request reconsideration of a claim denied for National Correct Coding Initiative (NCCI) reasons. Providers must submit an appeal instead.

resub comp Resubmission Turnaround Document (RTD) Completion 1

2 – Resubmission Turnaround Document (RTD) Completion December 2009

The Resubmission Turnaround Document (RTD) (Form 65-1) is sent to providers when a submitted claim form has questionable or missing information. This document, which is produced by the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) computer system, eliminates the need for providers to resubmit the entire claim form to correct a limited number of errors. A sample Resubmission Turnaround Document is on a following page (see Figure 1). All information in Section A of the RTD form is completed by the DHCS FI.

resub comp 2

2 – Resubmission Turnaround Document (RTD) Completion May 2010

Figure 1. Sample Resubmission Turnaround Document (RTD) (Form 65-1).

resub comp 3


Explanation of The following item numbers and descriptions correspond to the Form Items sample RTD on the previous page. The top of the form contains the instructions to complete the form and the date the corrected RTD must be received by the DHCS FI. Item Description

1. INFORMATION BLOCK. The name of the claim form box in question.

2. SUBMITTED INFORMATION. The information on the claim

form as entered into the Medi-Cal system.

3. SERVICE CODE. Procedure code, medical supply type code, or manufacturer billing code and drug code for the services being billed.

4. ERROR CODE. This is an internal Medi-Cal code. Multiple

error codes may be listed on the RTD.

5. DATE OF SERVICE. Date the service was rendered. RX NUMBER (Pharmacy only). Prescription number entered.

6. CORRECTED INFORMATION. This is for provider use. If

the information in Item 2 needs correcting, the correct information may be noted here for the provider’s records. The actual correction of the information that is sent to the

FI is entered in Section B, CORRECT INFORMATION (Item 21).

7. ERROR DESCRIPTION. This is the full explanation of the

error code that appears on the RTD (Item 4).

8. PROVIDER NAME AND ADDRESS.

9. PROVIDER NUMBER.

10. FINAL NOTICE. This is for FI use only.

11. DATE OF NOTICE.

12. NUMBER OF PAGES IN RTD.

13. SERVICE DATE(S)/PROVIDER REFERENCE NUMBER.

resub comp 4


Item Description

14. PRE-PRINTED INFORMATION. Identifies patient, Medi-Cal ID number, Medical Records Number and Total Charges. Also indicates the specific claim referenced (Claim Control Number).

15. CORRESPONDENCE REFERENCE NUMBER. Leave blank. This is for FI use only. 16. PROVIDER NUMBER. 17. PROVIDER NAME. 18. PATIENT MEDI-CAL ID NUMBER. This is the same number

entered by the provider on the original claim.

Note: If the claim suspends for recipient eligibility verification, the recipient identifier on the RTD is the same number as entered on the original claim.

19. PATIENT NAME. 20. F.I. USE ONLY. 21. CORRECT INFORMATION. In Section B of the RTD, enter

correct information in the numbered box that corresponds with the error line in the INFORMATION BLOCK (Item 1). If the information in Section A is correct, leave the corresponding line blank.

When entering correct information, enter all characters

(numbers and letters) exactly as they would be entered on the claim. Corrected information on the RTD must be in the same alphabetic or numeric format required on the claim form. See “Completing the RTD” on a following page.

22. SIGNATURE. All RTDs must be signed and dated by the

provider or an authorized representative. 23. BOXES 1 – 6. This space is no longer used.

resub comp 5


Completing the RTD When submitting correct information in Section B of an RTD, enter all characters as they would be entered on the claim form (see Figure 2 on a following page).

For example, enter the 11-digit TAR Control Number (TCN) on the

corresponding lines under “Correct Information” in Section B. This number should contain all numeric characters. Do not include letters or more digits than required on the claim; for example, both “TAR11123456789” and “011123456789” would be incorrect responses.

Note: For AEVS-verified recipients, do not use the 10-digit AEVS

verification number under “Correct Information.” Timeliness Return Section B (bottom portion) to the FI by the date indicated at the top of the form, and retain Section A (top portion) with a copy of the original claim. If the RTD is not returned by the provider before the due date

specified, or if the RTD is returned without the appropriate corrections or signatures, the claim will be denied.

Where to Submit RTDs The RTD must include an original signature of the provider or an authorized representative. RTDs must be mailed to the FI at the following post office box number:


Note: Do not mail RTDs and claim forms in the same envelope.

resub comp 6

2 – Resubmission Turnaround Document (RTD) Completion January 2008

Figure 2. Sample Resubmission Turnaround Document (RTD) (65-1): Completed Section B.

share op Share of Cost (SOC): UB-04 for Outpatient Services 1

2 – Share of Cost (SOC): UB-04 for Outpatient Services Outpatient Services 391 May 2007

This section explains how to complete claims for services rendered to recipients who paid a Share of Cost (SOC). The procedure codes used in the following examples are for illustration purposes only and may not be reimbursable to all provider types. Refer to the Share of Cost (SOC) section in the Part 1 manual for an explanation of SOC and how to determine the following:

• If a recipient must pay an SOC • The SOC amount a recipient must pay • If the recipient’s SOC is certified for the month

share op 2


SOC Field on Claim SOC is entered in the Value Codes and Amounts field (Boxes 39 – 41). Value code “23” in the “code” column of the field designates that the corresponding “amount” column contains the SOC. In the following example, the SOC amount of $50.00 is entered as 5000. Do not enter decimal points or dollar signs. Enter full dollar and cents amounts, even if the amount is even. Use only one claim line for each service billed. Refer to the UB-04 Completion: Outpatient Services section in this manual for additional information. This is a sample only. Please adapt to your billing situation.

Sample. Share of Cost Amount in Value Codes and Amounts Field (Boxes 39, 40 and 41).

share op 3


Billing Multiple Services Case Scenario: Three services are rendered to a recipient on Rendered on Different different dates. In this case, an outpatient clinic bills Z7500 Dates of Service (room use codes) for a recipient who requires stitches for his cut

hand. The recipient was seen twice on June 2, the first visit to stitch the laceration and the second visit to repair several stitches that came loose. The recipient was seen again on June 30 to remove the stitches.

Dates Service Amount SOC Cleared Balance 06/02/07 room use: $20.00 $20.00 0.00 06/02/07 room use: 20.00 20.00 0.00 06/30/07 room use: 20.00 10.00 10.00 Total 60.00 50.00 10.00 The recipient pays his entire $50 SOC and the provider performs SOC clearance transactions for each of the three services through the eligibility verification system. The recipient’s SOC, therefore, is certified and he is eligible for Medi-Cal. The provider submits a bill to Medi-Cal. Services rendered cost a total of $60. The first two services are not billed to Medi-Cal because the entire charge is paid as SOC by the recipient. The provider bills Medi-Cal for the last $20 service because the SOC covered only $10 of that charge. To bill, enter the $20 service fee in the Total Charges field (Box 47). Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23). Enter the amount of the patient’s SOC already applied toward the service fee ($10) in the Value Codes and Amounts field (Boxes 39 – 41). Enter value code “23” in Box 39A and the difference between Box 47 and Box 39 ($10) in the Estimated Amount Due field (Box 55).

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This is a sample only. Please adapt to your billing situation.

Sample. Multiple Services Rendered on Different Dates of Service. Box 80: Record Keeping For record keeping purposes only and to help reconcile payment on

the Remittance Advice Details (RAD), providers may show in the Remarks field (Box 80) the SOC amount that the recipient paid or obligated.

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Billing Multiple Services Case Scenario: Two services are rendered to a recipient on the same Rendered on Same date. In this case, a recipient visits the emergency room twice to see Date of Service a doctor about recurring chest pains. The outpatient clinic bills Z7502

(room use code).

Dates Service Amount SOC Cleared Balance 06/18/07 E.R. and

blood tests: $95.00 $60.00 35.00 06/18/07 Second E.R.

and blood tests: 29.50 0.00 29.50 Total 124.50 60.00 64.50 The recipient pays her entire $60 SOC and the provider performs SOC clearance transactions for each of the services through the eligibility verification system. The recipient’s SOC, therefore, is certified and she is eligible for Medi-Cal. The provider submits a bill to Medi-Cal that includes both same-day services on separate claim lines. To bill, enter the total services charged in the Total Charges (Box 47). Enter Code 001 in the Revenue Code column (Box 42, line 23) to designate that this is the total charge line and enter the totals of all charges in TOTALS (Box 47, line 23). Enter the amount of patient’s SOC applied to this claim in the Value Codes Amount field (Boxes 39 – 41). Enter value code “23” in Box 39A and the difference between Box 47 and Box 39 ($64.50) in the Estimated Amount Due field (Box 55).

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This is a sample only. Please adapt to your billing situation.

Sample. Multiple Services Rendered on the Same Date of Service. RAD Payment Summary SOC claims are reviewed prior to payment. Because the recipient’s

SOC is applied by the State to pay the $50 service billed on this claim, it may appear as “Denied” on the RAD (code 022), or with a payment amount of $.00. The other services will appear in the “Approved” category as partially paid. The Medi-Cal allowed amount for this service will be reduced by the remaining SOC amount. RAD code 408 indicates payment was reduced because of patient liability.

sign Sign Language Interpretation 1

2 – Sign Language Interpretation May 2009

This section contains policy related to sign language interpretation services. Sign Language Sign language interpreter services are a benefit to facilitate effective Interpreter Overview communication with deaf or hearing-impaired Medi-Cal recipients. The following services are reimbursable:

• Communication between a deaf or hearing-impaired Medi-Cal recipient and a Medi-Cal-enrolled provider during the course of a medically necessary health care examination or other procedure

• Communication between a deaf or hearing-impaired adult representative of the Medi-Cal recipient and a Medi-Cal-enrolled provider when necessary to facilitate medically necessary health services for the recipient

• Communication between a deaf or hearing-impaired adult who receives services or training on behalf of the recipient and the Medi-Cal-enrolled provider who renders the medically necessary health care services to the recipient

Provider Guidelines Sign language interpreter services are reimbursable only to providers

or provider groups employing fewer than 15 people. Health Facility Sign language interpreter services are not covered for recipients Limitations receiving these services in a health facility that is required by law to

provide sign language interpreter services.

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Interpreter Services Sign language interpreter services as defined in California Code of Guidelines Regulations (CCR), Title 22, Section 51098.5, may be used for, but

are not limited to, the following:

• Obtaining medical history • Obtaining informed consent and permission for treatment • Explaining diagnosis, treatment and prognosis of an illness • Communicating prior to, during and after medical procedures • Providing complex instructions regarding medication • Explaining instructions for care upon discharge from a medical

facility • Providing mental health assessment, therapy or counseling

The individual providing sign language interpreter services must:

• Not be related to the recipient • Possess the ability to receive, interpret and communicate

information effectively, accurately and impartially in a medical setting, as determined by both the recipient and the provider

• Be non-certified or hold certification by one of the following: – The National Registration of Interpreters for the Deaf (RID) – The National Association of Deaf (NAD)/California

Association of the Deaf (CAD) at competency Level IV or V only

– The California Department of Rehabilitation at competency Level III and possess a certificate from RID or NAD/CAD at competency Level IV or V only

Note: In an emergency or acute care situation, the provider may select the interpreter.

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Reimbursable HCPCS Codes The following HCPCS codes are reimbursable for sign language interpreter services.

Authorization Authorization is not required.

HCPCS Code

Description

Z0324 Sign language interpreter services; certified, basic, two-hour minimum Reimbursement: $64.55 Frequency: Limited to one per day, per provider, per

recipient Z0326 Sign language interpreter services; non-certified, basic,

two-hour minimum Reimbursement: $38.73 Frequency: Limited to one per day, per provider, per

recipient Z0328 Sign language interpreter services; certified, each additional

15-minute increment This code is for use when the time spent providing sign language interpreter services exceeds the basic two-hour minimum service due to lengthy or multiple medical appointments and must be billed with code Z0324. Reimbursement: $6.36 * Frequency: Limited to a total of 24 15-minute increments

per provider, per recipient, per day Z0329 Sign language interpreter services; non-certified, each

additional 15-minute increment This code is for use when the time spent providing sign language interpreter services exceeds the basic two-hour service and must be billed with code Z0326. Reimbursement: $3.82 * Frequency: Limited to a total of 24 15-minute increments

per provider, per recipient, per day

* Incremental rates for services exceeding the two-hour minimum are based on salary and benefits only and do not include a factor for mileage.

Billing Providers must document that they employ fewer than 15 employees

in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) or on a claim attachment. Sign language interpreter services may not be billed using the “from-through” format.

ub comp op UB-04 Completion: Outpatient Services 1

2 – UB-04 Completion: Outpatient Services Outpatient Services 398 November 2007

The UB-04 claim form is used to submit claims for outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis services and Adult Day Health Care). See UB-04 Completion: Inpatient Services in the Part 2 Inpatient Services Manual for billing instructions for services rendered to a registered hospital inpatient. If the patient is treated as an outpatient in a hospital different from the one in which the patient is registered, the services must be billed by the treating hospital using the UB-04 claim form with the appropriate facility type code (which is the first two digits in the Type of Bill field [Box 4]) for the outpatient facility. Most claims for outpatient services can also be submitted through Computer Media Claims (CMC). For CMC ordering and enrollment information, refer to the CMC section in the Part 1 manual. For additional billing information, refer to the UB-04 Special Billing Instructions for Outpatient Services, UB-04 Submission and Timeliness Instructions and UB-04 Tips for Billing: Outpatient Services sections in this manual. LEA Providers: Timeliness limitations differ for Local Educational Agency (LEA) providers. LEA providers

refer to the Local Educational Agency (LEA) Billing and Reimbursement Overview section.

For crossover billing information, refer to the Medicare/Medi-Cal Crossover Claims: Outpatient Services and Medicare/Medi-Cal Crossover Claims: Outpatient Services Billing Examples. Medi-Cal cannot process credits or adjustments on the UB-04 form. Refer to the CIF Completion and CIF Special Billing Instructions for Outpatient Services sections in the appropriate Part 2 manual for information about claim adjustments.

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2 – UB-04 Completion: Outpatient Services Outpatient Services 401 February 2008

Figure 1. UB-04 Claim: Medi-Cal Required Fields for Outpatient Claims.

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Explanation of Form Items The following item numbers and descriptions correspond to the UB-04 claim form on the previous page. All items must be completed unless

otherwise noted. Note: Items described as “Not required by Medi-Cal” may be

completed for other payers, but are not recognized by the Medi-Cal claims processing system.

Item Description

1. UNLABELED (Use for clinic or facility information). Enter the clinic or facility name. Enter the address, without a comma between the city and state, and a nine-digit ZIP code, without a hyphen. A telephone number is optional in this field. Note: The nine-digit ZIP code entered in this box must match

the biller’s ZIP code on file for claims to be reimbursed correctly.

2. UNLABELED. For FI use only. This field must be left blank

on all claims submitted to Medi-Cal.

3A. PATIENT CONTROL NUMBER. This is an optional field that will help you to easily identify a recipient on Resubmission

Turnaround Documents (RTDs) and Remittance Advices (RAs). Enter the patient’s financial record number or account number in this field. A maximum of 20 numbers

and/or letters may be used, but only 10 characters will appear on the RTD and RA. Refer to the Remittance Advice Details (RAD) Examples: Outpatient Services section in this manual

for patient control number information. 3B. MEDICAL RECORD NUMBER. Not required by Medi-Cal.

Use Box 3A to enter a patient control number. This number will not appear on the RTD or RA for recipient clarification. The patient control number (Item 3) will appear on the RTD and RA.

4. TYPE OF BILL. Enter the appropriate three-character

type of bill code as specified in the National Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual. The type of bill code includes the two-digit facility type code and one-character claim frequency code. This is a required field when billing Medi-Cal.

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2 – UB-04 Completion: Outpatient Services Outpatient Services 419 August 2009

Item Description

4. TYPE OF BILL (continued). The following facility type codes are a subset of the National

Uniform Billing Committee (NUBC) UB-04 Data Specifications Manual facility type codes commonly used by Medi-Cal.

Use one of the following codes as the first two digits of the

three-character type of bill code:

Code Facility Type 11 Hospital – Inpatient (Including Medicare Part A) 12 Hospital – Inpatient (Medicare Part B only) 13 Hospital – Outpatient 14 Hospital – Other (For hospital referenced

diagnostic services, or home health not under a plan of treatment). Use admit type “1” when billing for emergency services.

18 Hospital – Swing Beds 21 Skilled Nursing – Inpatient (Includes Medicare

Part A 22 Skilled Nursing – Inpatient (Includes Medicare

Part B 23 Skilled Nursing – Outpatient 24 Skilled Nursing – Clinic (For hospital referenced

diagnostic services, or home health not under a plan of treatment)

25 Skilled Nursing – Intermediate Care Level II (Level A)

26 Skilled Nursing – Intermediate Care Level II (Level B)

27 Skilled Nursing – Subacute (Use modifier HB to indicate adult or HA to indicate child)

28 Skilled Nursing – Swing Beds 32 Home Health – Inpatient (Plan of treatment

under Part B only) 33 Home Health – Outpatient (Plan of treatment

under Part A only, including Durable Medical Equipment (DME) under Part A

34 Home Health – Other (For medical and surgical services not under a plan of treatment)

41 Religious Non-Medical Health Care Institutions – Hospital Inpatient

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2 – UB-04 Completion: Outpatient Services Outpatient Services 419 August 2009

Item Description 4. TYPE OF BILL (continued).

Code Facility Type

43 Religious Non-Medical Health Care Institutions – Outpatient Services

44 Religious Non-Medical Health Care Institutions, Hospital Inpatient – Other (For hospital referenced diagnostic services, or home health not under a plan of treatment)

54 Religious Non-Medical Health Care Institutions, Post Hospital Extended Care Services – Other (For hospital referenced diagnostic services, or home health not under a plan of treatment)

64 Intermediate Care – Other (For hospital referenced diagnostic services or home health not under a plan of treatment)

65 Intermediate Care – Intermediate Care Level I 66 Intermediate Care – Level II 71 Clinic – Rural Health 72 Clinic – Hospital Based or Independent Renal

Dialysis Center 73 Clinic – Free Standing 74 Clinic – Outpatient Rehabilitation Facility (ORF) 75 Clinic – Comprehensive Outpatient Rehabilitation

Facility (CORF) 76 Clinic – Community Mental Health Center 79 Clinic – Other 81 Special Facility – Hospice (Non-hospital based) 82 Special Facility – Hospice (Hospital based) 83 Special Facility – Ambulatory Surgery Center 84 Special Facility – Free Standing Birthing Center 85 Special Facility – Critical Access Hospital 86 Special Facility – Residential Facility 89 Special Facility – Other

Notes: Only one facility type may be billed on each claim.

Outpatient services not logically compatible with the facility type identified on the claim must be billed on a separate claim.

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2 – UB-04 Completion: Outpatient Services Outpatient Services 391 May 2007

Item Description 4. TYPE OF BILL (continued). Clinics and outpatient hospitals use one of the following codes

as the first two digits of the three-character type of bill code:

Provider Type Facility Type

AIDS Waiver Agency 13, 33, 79 Chronic Dialysis Clinic 72 Community Hospital, Outpatient 13 Community Mental Health Clinic 76 Employer/Employee Clinic 79 Exempt from Licensure Clinic 79 Free Clinic 79 Home Health Agency 33 Local Educational Agency 89 Multispecialty Clinic 79 Rehab Clinic 74 Rehab Clinic (Comprehensive) 75 Rural Health Clinic 71 Surgical Clinic 73, 79

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Item Description 5. FEDERAL TAX NUMBER. Not required by Medi-Cal. 6. STATEMENT COVERS PERIOD (From-Through). Not

required by Medi-Cal. 7. UNLABELED. Not required by Medi-Cal. 8A. PATIENT NAME – ID. Not required by Medi-Cal. 8B. PATIENT NAME. Enter the patient’s last name, first name

and middle initial (if known). Avoid nicknames or aliases.

Newborn Infant When submitting a claim for a newborn infant using the mother’s ID number, enter the infant’s name in Box 8B. If the

infant has not yet been named, write the mother’s last name followed by “Baby Boy” or “Baby Girl” (example: Jones, Baby Girl). If billing for newborn infants from a multiple birth, each newborn must also be designated by number or letter (example: Jones, Baby Girl, Twin A) on separate claims.

Enter the infant’s date of birth and sex in Boxes 10 and 11. Enter the mother’s name in Box 58 (Insured’s Name), and enter “03” (CHILD) in Box 59 (Patient’s Relationship to Insured).

Organ Donors When submitting a claim for a patient donating an organ to a

Medi-Cal recipient, enter the donor’s name, date of birth and sex in the appropriate boxes. Enter the Medi-Cal recipient’s name in Box 58 (Insured’s Name) and enter “11” (DONOR) in Box 59 (Patient’s Relationship to Insured).

9A-E. PATIENT ADDRESS. Not required by Medi-Cal. 10. BIRTHDATE. Enter the patient’s date of birth in an eight-digit

MMDDYYYY (Month, Day, Year) format (for example, September 16, 1967 = 09161967). If the recipient’s full date of birth is not available, enter the year preceded by 0101. (For newborns and organ donors, see Item 8B.)

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Item Description 11. SEX. Use the capital letter “M” for male, or “F” for female.

Obtain the sex indicator from the Benefits Identification Card. (For newborns and organ donors, see Item 8B on a previous page.)

12. ADMISSION DATE. Not required by Medi-Cal. 13. ADMISSION HOUR. Not required by Medi-Cal. 14. ADMISSION TYPE. Enter admit type code “1” in conjunction

with facility type “14” when billing for emergency room-related services. Not required by Medi-Cal for any other use. See “Emergency Certification” under Condition Codes (Items 18 – 24) on a following page for additional information.

15. ADMISSION SOURCE. Not required by Medi-Cal. 16. DISCHARGE HOUR. Not required by Medi-Cal. 17. STATUS. Not required by Medi-Cal.

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Item Description

18 – 24. CONDITION CODES. Condition codes are used to identify conditions relating to this claim that may affect payer processing.

Although the Medi-Cal claims processing system only recognizes the condition codes on the following pages, providers may include codes accepted by other payers. The claims processing system ignores all codes not applicable to Medi-Cal. Condition codes should be entered from left to right in numeric-alpha sequence starting with the lowest value. For example, if billing for three condition codes, “A1”, “80” and “82”, enter “80” in Box 18, “82” in Box 19 and “A1” in Box 20. Applicable Medi-Cal codes are: Other Coverage: Enter code “80” if recipient has Other Health Coverage (OHC). OHC includes insurance carriers as well as Prepaid Health Plans (PHPs) and Health Maintenance Organizations (HMOs) that provide any of the recipient’s health care needs. Eligibility under Medicare or a Medi-Cal managed care plan is not considered other coverage and is identified separately. Medi-Cal policy requires that, with certain exceptions, providers must bill the recipient’s other health insurance prior to billing Medi-Cal. (For details about OHC, refer to the Other Health Coverage (OHC) Guidelines for Billing section in the Part 1 manual.) Emergency Certification: Enter code “81” if billing for emergency services. An Emergency Certification Statement must be attached to the claim or entered in the Remarks field (Box 80). The statement must be signed by the attending provider. It is required for all OBRA/IRCA recipients and any service rendered under emergency conditions that would otherwise have required prior authorization such as emergency services by allergists, podiatrists, medical transportation providers, portable X-ray providers, psychiatrists and out-of-state providers. These statements must be signed and dated by the provider and must be supported by a physician, podiatrist or dentist’s statement describing the nature of the emergency, including relevant clinical information about the patient’s condition. A mere statement that an emergency existed is not sufficient. If the Emergency Certification Statement will not fit in the Remarks field (Box 80) area, attach the statement to the claim.

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Item Description 18 – 24. CONDITION CODES (continued). Outside Laboratory: Enter code “82” if this claim includes

charges for laboratory work performed by a licensed laboratory. “Outside” laboratory (facility type “89”) refers to a laboratory not affiliated with the billing provider. State in the

Remarks field (Box 80) that a specimen was sent to an unaffiliated laboratory.

Family Planning/CHDP: Enter code “AI” or “A4” if the services rendered are related to Family Planning (FP). Enter code “A1” if the services rendered are Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/Child Health and Disability Prevention (CHDP) screening related. Leave blank if not applicable.

Code Description A1 EPSDT/CHDP A4 Family Planning AI Sterilization/Sterilization Consent Form (PM 330) must

be attached if code “AI” is entered See Family Planning and Sterilization sections in the appropriate Part 2 manual for further information.

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Item Description 18 – 24. CONDITION CODES (continued).

Medicare Status: Medicare status codes are required for Charpentier claims. In all other circumstances, these codes are optional; therefore, providers may leave this area of the Condition Codes fields (Boxes 18 – 24) blank. The Medicare status codes are:

Code Description Y0 Under 65, does not have Medicare coverage Y1 * Benefits exhausted Y2 * Utilization committee denial or physician

non-certification Y3 * No prior hospital stay Y4 * Facility denial Y5 * Non-eligible provider Y6 * Non-eligible recipient Y7 * Medicare benefits denied or cut short by Medicare

intermediary Y8 Non-covered services Y9 * PSRO denial Z1 * Medi/Medi Charpentier: Benefit Limitations Z2 * Medi/Medi Charpentier: Rates Limitations Z3 * Medi/Medi Charpentier: Both Rates and Benefit

Limitations * Documentation required. Refer to the Medicare/

Medi-Cal Crossover Claims: Outpatient Services section in the appropriate Part 2 manual for more information.

25 – 28. CONDITION CODES. The Medi-Cal claims processing

system only recognizes condition codes entered in Boxes 18 – 24.

29. ACDT STATE. Not required by Medi-Cal.

30. UNLABELED. Not required by Medi-Cal.

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Item Description 31 – 34 A – B. OCCURRENCE CODES AND DATES. Occurrence codes

and dates are used to identify significant events relating to a claim that may affect payer processing.

Occurrence codes and dates should be entered from left to

right, top to bottom in numeric-alpha sequence starting with the lowest value. For example, if billing for two occurrence codes “24” (accepted by another payer) and ”05” (accident/no

medical or liability coverage), enter “05” in Box 31A and “24” in Box 32A. Refer to Figure 2 below.

Figure 2. Occurrence Codes Example.

Although the Medi-Cal claims processing system will only recognize the following codes, providers may include codes and dates billed to other payers in Boxes 31 – 34. The claims processing system will ignore all codes not applicable to Medi-Cal.

Applicable Medi-Cal codes are: Enter code “04” (accident/employment-related) in Boxes 31

through 34 if the accident or injury was employment related. Enter one of the following codes if the accident or injury was non-employment related:

Code Description 01 Accident/medical coverage 02 No fault insurance involved – including auto

accident/other 03 Accident/tort liability 05 Accident/no medical or liability coverage 06 Crime victim

In six-digit MMDDYY (Month, Day, Year) format, enter the date

of accident/injury in the corresponding box. 35 – 36 A – B. OCCURRENCE SPAN CODES AND DATES. Not required by

Medi-Cal.

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Item Description

37A. UNLABELED (Use for delay reason codes). Enter one of the following delay reason codes and include the required documentation if there is an exception to the six-months-from-the-month-of-service billing limit.

Code Description Documentation 1 Proof of Eligibility unknown or

unavailable Remarks/ Attachment

3 Authorization delays Remarks 4 Delay in certifying provider Remarks 5 Delay in supplying billing forms Remarks 6 Delay in delivery of

custom-made appliances Remarks

7 Third party processing delay Attachment 10 Administrative delay in prior

approval process (decision appeals)

Attachment

11 Other (no reason) None * 11 Other (theft, sabotage) Attachment * 15 Natural disaster Attachment

* Documentation justifying the delay reason must be attached to the claim to receive full payment. Providers billing with delay reason “11” without an attachment will either receive reimbursement at a reduced rate or a claim denial. Refer to “Reimbursement Reduced for Late Claims” in the UB-04 Submission and Timeliness Instructions section of this manual.

Also refer to the UB-04 Submission and Timeliness

Instructions section for additional information about codes and documentation requirements.

37B. UNLABELED. Not required by Medi-Cal. 38. UNLABELED. Not required by Medi-Cal.

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Item Description 39 – 41 A – D. VALUE CODES AND AMOUNT. Patient’s Share of Cost.

Value codes and amounts should be entered from left to right, top to bottom in numeric-alpha sequence, starting with the lowest value. For example, if billing for two value codes “30” (accepted by another payer) and “23” (accepted by Medi-Cal), enter “23” in Box 39A and “30” in Box 40A. (See Figure 3 below.)

Value codes and amounts are used to relate amounts to data elements necessary to process the claim. Although the Medi-Cal claims processing system only recognizes code “23,” providers may include codes and dates billed to other payers in Boxes 39 – 41. The claims processing system will ignore all codes not applicable to Medi-Cal. Enter code “23” and the amount of the patient’s Share of Cost for the procedure or service, if applicable. Do not enter a decimal point (.), dollar sign ($), positive (+) or negative (-) sign. Enter full dollar amount and cents, even if the amount is even (for example, if billing for $100, enter 10000 not 100). For more information about Share of Cost, see the Share of Cost: UB-04 for Outpatient Services section in this manual.

Figure 3. Value Codes Example.

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2 – UB-04 Completion: Outpatient Services Outpatient Services 418 July 2009

Item Description 39 – 41 A – D. VALUE CODES AND AMOUNT. Patient’s Share of Cost

(continued).

42. REVENUE CODE. Revenue codes are not required by Medi-Cal.

Total Charges: Enter “001” on line 23, and enter the total amount on line 23, field 47.

43. DESCRIPTION. This field will help you separate and identify

the descriptions of each service. The description must identify the particular service code indicated in the

HCPCS/Rate/HIPPS Code field (Box 44). For more information, refer to the CPT-4 code book. This field is

optional except when billing for physician-administered drugs. Entering the National Drug Code (NDC) for Physician-

Administered Drugs: Enter the product ID qualifier N4 followed by the 11-digit NDC (no spaces or hyphens). Directly following the last digit of the NDC (no space), enter the two-character unit of measure qualifier followed by the numeric quantity. Refer to the Physician-Administered Drugs – NDC: UB-04 Billing Instructions section in this manual for more information.

Notes: 1) Unit of measure and numeric quantity are optional.

Absence of these two elements will not result in claim denial.

2) If there are multiple pages of the claim, enter the page numbers on line 23 in this field.

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Item Description

44. HCPCS/RATE/HIPPS CODE. Enter the applicable procedure or drug code (CPT-4 or HCPCS) and modifier(s). Note that the descriptor for the code must match the procedure performed and that the modifier(s) must be billed appropriately.

Attach reports to the claim for “By Report” codes, complicated procedures (modifier 22) and unlisted services. Reports are not required for routine procedures. Non-payable CPT-4 codes are listed in the TAR and Non-Benefit List: Codes (10000 – 99999) sections in the appropriate Part 2 manual.

Up to four modifiers may be entered on outpatient UB-04 claims. All modifiers must be billed immediately following the HCPCS code in the HCPCS/Rate field (Box 44) with no spaces. (See Figure 4.)

Note: Providers billing for physician-administered drugs

subject to the federally established 340B Drug Pricing Program must include the modifier following the HCPCS code. Section 340B drugs may be billed on the same claim as non-340B drugs.

For a listing of modifier codes, refer to the Modifiers: Approved List section in the appropriate Part 2 manual.

Figure 4. UB-04 Claim: Codes and Modifiers Example. Medicare/Medi-Cal If billing for services to a recipient with both Medicare and Recipients Medi-Cal, refer to the Medicare Non-Covered Services

sections in the appropriate Part 2 Outpatient Services manual to check the list of Medicare non-covered services codes. Only those services listed in a Medicare Non-Covered Services section may be billed directly to Medi-Cal. All others must be billed to Medicare first.

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Item Description

45. SERVICE DATE. Enter the date the service was rendered in six-digit, MMDDYY (Month, Day, Year) format, for example, June 24, 2003 = 062403.

“From-Through” Billing For “From-Through” billing instructions, refer to the UB-04

Special Billing Instructions for Outpatient Services section in this manual.

46. SERVICE UNITS. Enter the actual number of times a single

procedure or item was provided for the date of service. Medi-Cal only allows two digits in this field. If billing for more than 99, divide the units on two or more lines.

47. TOTAL CHARGES. In full dollar amount, enter the usual and

customary fee for the service billed. Do not enter a decimal point (.) or dollar sign ($). Enter full dollar amount and cents, even if the amount is even (for example, if billing for $100, enter 10000 not 100). If an item is a taxable medical supply, include the applicable state and county sales tax.

Note: Medi-Cal cannot process credits or adjustments on the UB-04 form. Refer to the CIF Completion and CIF Special Billing Instructions for Outpatient Services sections in the appropriate Part 2 manual for

information regarding claim adjustments.

Enter the “Total Charge” for all services on line 23. Enter code 001 in Revenue Code field (Box 42) to indicate that this is the total charge line (refer to Item 42 on a preceding page).

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Item Description

48. NON-COVERED CHARGES. Not required by Medi-Cal. 49. UNLABELED. Not required by Medi-Cal.

Note: Providers may enter up to 22 lines of detail data (Items 42 – 49). It is also acceptable to skip lines.

To delete a line, mark through the boxes as shown in Figure 5. Be sure to draw a thin line through the entire detail line using a blue or black ballpoint pen.

Figure 5. UB-04 Claim: Line Deletion Example.

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Item Description 50A – C. PAYER NAME. Enter “O/P MEDI-CAL” to indicate the type of

claim and payer. Use capital letters only. Refer to Figure 6.

When completing Boxes 50 – 65 (excluding Box 56) enter all information related to the payer on the same line (for example, Line A, B or C) in order of payment (Line A: other insurance, Line B: Medicare, Line C: Medi-Cal). Do not enter information on Lines A and B for other insurance or Medicare if payment was denied by these carriers.

When billing other insurance, the other insurance is entered on Line A of Box 50, with the amount paid by Other Coverage on Line A of Box 54 (Prior Payments). All information related to the Medi-Cal billing is entered on Line B of these boxes. Be sure to enter the corresponding prior payments on the correct line.

If Medi-Cal is the only payer billed, all information in Boxes 50 – 65 (excluding Box 56) should be entered on Line A. Reminder: If the recipient has Other Health Coverage, the

insurance carrier must be billed prior to billing Medi-Cal.

Figure 6. UB-04 Claim: Payer Name Example.

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Item Description 51A – C. HEALTH PLAN ID. Not required by Medi-Cal. 52A – C. RELEASE OF INFORMATION CERTIFICATION

INDICATOR. Not required by Medi-Cal. 53A – C. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR.

Not required by Medi-Cal. 54A – B. PRIOR PAYMENTS (Other Coverage). Enter the full dollar

amount of payment received from Other Health Coverage on the same line as the Other Health Coverage “payer” (Box 50). Do not enter a decimal point (.), dollar sign ($), positive (+) or negative (-) sign. Leave blank if not applicable.

Note: For instructions about completing this field for Medicare/Medi-Cal crossover recipients, refer to the Medicare/Medi-Cal Crossover Claims: Outpatient

Services section in this manual.

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Item Description 55A – C. ESTIMATED AMOUNT DUE (Net amount billed). In full

dollar amount, enter the difference between “Total Charges” and any deductions (for example, patient’s Share of Cost and/or Other Coverage). Do not enter a decimal point (.) or dollar sign ($).

Total Charges (Box 47) Revenue code 001

(Minus) – Deductions Share of Cost (Box 39, 40 or 41A – D/ Value code 23) and Other Coverage (Box 54A or B)

(Equals) = Net Billed (Boxes 55A – C) 56. NPI. Enter the National Provider Identifier (NPI). 57A – C. OTHER (BILLING) PROVIDER ID (Used by atypical

providers only). Enter the Medi-Cal provider number, corresponding to information on lines A, B or C. Note: Required prior to the mandated NPI implementation

date when an additional identification number is necessary to identify the provider, or if on and after the mandated NPI implementation, the NPI is not used in Box 56 and an identification number other than the NPI is necessary for the receiver to identify the provider.

58A – C. INSURED’S NAME. If billing for an infant using the mother’s

ID or for an organ donor, enter the Medi-Cal recipient’s name here and the patient’s relationship to the Medi-Cal recipient in

Box 59 (Patient’s Relationship to Insured). See Item 8B on a previous page. This box is not required by Medi-Cal except under the two circumstances listed in Item 8B. 59A – C. PATIENT’S RELATIONSHIP TO INSURED. If billing for an

infant using the mother’s ID or for an organ donor, enter the code indicating the patient’s relationship to the Medi-Cal recipient (for example, “03” [CHILD] or “11” [DONOR]). See

Item 8B on a previous page. This box is not required by Medi-Cal except under the two circumstances listed in Item 8B.

ub comp op 22


Item Description 60A – C. INSURED’S UNIQUE ID. Enter the 14-character recipient ID number as it appears on the Benefits Identification Card (BIC)

or paper Medi-Cal ID card. Note: Medi-Cal does not accept HIC Numbers. Newborn Infant When submitting a claim for a newborn infant for the month of

birth or the following month, enter the mother’s ID number in this field. (For more information, see Item 8B on a previous page.) 61A – C. GROUP NAME. Not required by Medi-Cal. 62A – C. INSURANCE GROUP NUMBER. Not required by Medi-Cal. 63A – C. TREATMENT AUTHORIZATION CODES. For services

requiring a Treatment Authorization Request (TAR), enter the 11-digit TAR Control Number. It is not necessary to attach a copy of the TAR to the claim. Recipient information on the claim must match the TAR. Multiple claims must be submitted for services that have more than one TAR. Only one TAR Control Number can cover the services billed on any one claim.

Note: TAR and non-TAR procedures should not be combined

on the same claim. 64A – C. DOCUMENT CONTROL NUMBER. Not required by

Medi-Cal. 65A – C. EMPLOYER NAME. Not required by Medi-Cal.

ub comp op 23

2 – UB-04 Completion: Outpatient Services Outpatient Services 418 July 2009

Item Description 66. DIAGNOSIS CODE HEADER. Not required by Medi-Cal. 67. UNLABELED (Use for primary diagnosis code). Enter all

letters and/or numbers of the ICD-9-CM code for the primary diagnosis, including fourth and fifth digits if present. Do not enter a decimal point when entering the code.

67A. UNLABELED (Use for secondary diagnosis code). If

applicable, enter all letters and/or numbers of the secondary ICD-9-CM code, including fourth and fifth digits if present. Do not enter a decimal point when entering the code.

Note: Medi-Cal only accepts two diagnosis codes. Codes

entered in Boxes 67B – Q and 68 will not be used for claims processing.

67B – Q. UNLABELED. Not required by Medi-Cal. 68. UNLABELED. Not required by Medi-Cal. 69. ADMITTING DIAGNOSIS. Not required by Medi-Cal. 70. PATIENT REASON DIAGNOSIS. Not required by Medi-Cal. 71. PPS CODE. Not required by Medi-Cal.

ub comp op 24


Item Description 72. EXTERNAL CAUSE OF INJURY CODE. Not required by

Medi-Cal. 73. UNLABELED. Not required by Medi-Cal.

74. PRINCIPAL PROCEDURE CODE AND DATE. Not required by Medi-Cal.

74A – E. OTHER PROCEDURE CODE AND DATE. Not required by Medi-Cal.

75. UNLABELED. Not required by Medi-Cal.

ub comp op 25

2 – UB-04 Completion: Outpatient Services Outpatient Services 403 April 2008

Item Description

76. ATTENDING. In the first box, enter the provider number of the referring or prescribing physician. This field is mandatory for radiologists. If the physician is not a Medi-Cal provider, enter the state license number. Do not use a group provider number. The referring or prescribing physician’s first and last names are not required by Medi-Cal.

77. OPERATING. In the first box, enter the provider number of

the facility in which the recipient resides or of the physician actually providing services. Only one rendering provider number may be entered per claim form. Do not use a group provider number or state license number. The rendering physician’s first and last names are not required by Medi-Cal.

78. OTHER. Not required by Medi-Cal. 79. OTHER. Not required by Medi-Cal.

80. REMARKS. Use this area for procedures that require additional information, justification or an Emergency Certification Statement. The Emergency Certification Statement is required for all OBRA/IRCA recipients, and any service rendered under emergency conditions that would otherwise have required prior authorization, such as, emergency services by allergists, podiatrists, medical transportation providers, portable X-ray providers, psychiatrists and out-of-state providers. These statements must be signed and dated by the provider, and must be supported by a physician, podiatrist or dentist’s statement describing the nature of the emergency, including relevant clinical information about the patient’s condition. A mere statement that an emergency existed is not sufficient. If the Emergency Certification Statement will not fit in the Remarks field (Box 80), attach the statement to the claim.

81A – D. CODE-CODE. Not required by Medi-Cal.

UB-04 Special Billing Instructions ub spec op for Outpatient Services 1

2 – UB-04 Special Billing Instructions for Outpatient Services Outpatient Services 391 May 2007

This section includes information about “By Report” attachments to claims, “from-through” billing and submitting claims for Treatment Authorization Request-approved procedures. This information is designed to supplement the explanations in the UB-04 Completion: Outpatient Services section of this manual. “By Report” Attachments The Medical Review Unit is unable to process “By Report” claims

without the following information on the “By Report” attachment:

• Patient name.

• Date of service.

• Procedure number (list supplemental procedures if applicable).

• Operating report and operating time, or procedure report. Each report must include a description of the actual procedure performed on the patient and the results of the procedure. Pro forma or “canned” reports are unacceptable.

• Estimated follow-up days required.

• Size, number and location of lesions (if applicable).

• When billing unlisted “By Report” procedures (no specific description of service, such as CPT-4 code 36299 [unlisted vascular injection procedure]), also state the time involved, the nature and purpose of the procedure or service and how it relates to diagnosis.

Using Remarks Field “By Report” claim submissions do not always require a claim In Place of Attachments attachment. For some procedures, entering information in the

Remarks field (Box 80) of the claim may be sufficient.

Note: Many radiology and pathology “By Report” procedures require only a description in the Remarks field (Box 80) of the claim

POS and Internet Point of Service (POS) printouts and Internet eligibility responses, with

Eligibility Verification Confirmation (EVC) numbers, are not required as attachments unless the claim is over 1 year old.

ub spec op 2


“From-Through” “From-through” billing is a method of billing that allows providers Billing to bill for the same service rendered on different dates of service,

without having to complete a separate claim line for each date of service. Only specific services identified in applicable policy sections may be billed in this manner.

Billing Procedures Inappropriate use of the “from-through” billing format may result in

claim denial. Refer to Figure 1. “From-Through” Billing Example on the following page.

LINE 1: Begin the procedure description in the Description field

(Box 43). Enter the from date of service in the Service Date field (Box 45) and align it with the beginning of the procedure description. No other information is entered on the first line.

LINE 2: Continue procedure description started on line 1, if necessary, and list all dates of service. Enter the procedure code for service rendered in the HCPCS/Rate field (Box 44), followed by the through date in the Service Date field (Box 45). The number of units being billed is entered in the Service Units field (Box 46). If the quantity exceeds 99, bill the remaining services on individual claim lines or in additional “from-through” format(s). Enter the total of the Service Units times the maximum allowable amount for the designated procedures in the Total Charges field (Box 47).

Note: For electronic billing, enter the description in the Remarks field (Box 80) and a “1” in the Service Units field.

Complete the rest of the fields as instructed in the appropriate policy section and/or the UB-04 Completion: Outpatient Services section in this manual.

ub spec op 3


Consecutive/ “From-through” billing may be used for both consecutive and Non-Consecutive Days non-consecutive days of service. Unit Type as “Month” Procedure codes with a unit type of “Month” must be billed using the “from-through” method. Figure 1, below, is an example of “From-Through” billing.

Figure 1. “From-Through” Billing Example. Line-Item Billing Line-item billing is illustrated in Figure 2 below. This method must be

used for all services on the UB-04 claim, except when using the “from-through” billing method.

Figure 2. Line-Item Billing Example.

ub spec op 4

2 – UB-04 Special Billing Instructions for Outpatient Services Outpatient Services 398 November 2007

Submitting Claims for Providers bill Medi-Cal for Treatment Authorization Request TAR-Authorized Services (TAR)-authorized services only after receiving the approved TAR

from the Medi-Cal field office. If the TAR approval process causes a delay in submitting claims, providers (except LEA providers) may request an extension of the usual six-month billing limit by entering the

appropriate delay reason code in the Delay Reason field (Box 37A) of the claim.

To submit a claim for services authorized by a TAR, providers should:

• Ensure that the procedure codes, modifiers and dates of

service on the claim match exactly those shown on the approved TAR. The cumulative number of units billed (for each procedure) against a particular TAR must not exceed the number of units approved by the TAR.

• Enter the 11-digit TAR Control Number (TCN) from the approved TAR in the Treatment Authorization Codes field (Box 63) on the UB-04 claim. Enter the TCN only from a 50-1 TAR form. TCNs from other TAR forms (18-1 or 20-1) are used only by hospitals and facilities.

• Enter the TCN on all claims for services authorized on one TAR, even if the services are billed separately.

Multiple TARs/ Items or procedures approved on separate TAR forms must be billed Separate Claims on separate claim forms. Items covered on two TARs must not be

combined on a single claim. See “Multiple TARs” in the TAR Completion section of this manual.

“From-Through” Providers must not mix the TAR-authorized and non-TAR- authorized Billing services in the same “from-through” billing period.

ub spec op 5

2 – UB-04 Special Billing Instructions for Outpatient Services Outpatient Services 398 November 2007

Submitting Providers must not submit copies of TARs with claims or Copies of TARs Resubmission Turnaround Documents (RTDs) as proof of

authorization. Instead, providers should accurately and legibly copy the entire 11-digit TAR Control Number in the TAR control box on the claim form or RTD. Omissions, errors or illegibility will cause claim denial.

TAR Copy Exceptions Providers may submit copies of TARs with appeals and Claims Inquiry

Forms (CIFs) to show that there is an error in the TAR information. TAR Corrections Providers may request the Medi-Cal field office to correct or modify for TARs Over recipient information on a TAR within a year of the TAR’s original One Year Old approval date. The Department of Health Care Services (DHCS)

consultant will not change the recipient’s Medi-Cal ID number, Social Security Number (SSN), name, date of birth or sex if the TAR is more than one year old.

Mismatched TAR and If a claim is denied because the recipient data on the claim does not Claim Data match the recipient data on the TAR, providers may request claim

reconsideration by attaching a copy of a TAR to a CIF.

ub spec op 6


TARs and Providers must submit two separate claims if a combination of Medi-Services Medi-Services and TAR-authorized services are being billed to

substantiate services rendered to a recipient during a single billing period. For example, a podiatrist sees a patient in his office on September 6, reserving a Medi-Service, and then sees the patient on September 16 and 30 in a Nursing Facility Level B (NF-B) under an approved treatment plan. One claim must be submitted for the Medi-Service office visit. A second claim must be submitted for the NF-B visits, indicating the TAR Control Number on the claim.

Billing TAR and The following information relates to billing TAR and non-TAR Non-TAR Authorized authorized procedures. Procedures DME and Medical Supplies TAR-authorized procedures for Durable Medical Equipment (DME)

and Medical Supplies are billed on a separate claim from non-TAR authorized procedures.

Note: Claims submitted to Medi-Cal for DME, medical supplies,

incontinence medical supplies and prosthetic and orthotic appliances identified with a single asterisk in the California Code of Regulations (CCR), Title 22, Section 51515, shall not exceed an amount that is the lesser of (1) the usual charges made to the general public or (2) the net purchase price of the item, which must be documented in the provider’s books and records, plus no more than a 100 percent markup (CCR, Title 22, Section 51008.1).

Providers are also prohibited from submitting claims for DME, supplies and appliances that were obtained at no cost (CCR, Title 22, Section 51008.1). This regulation does not alter Medi-Cal’s statutory or regulatory maximum reimbursement rates.

Surgical Procedures TAR and non-TAR surgical procedure codes (HCPCS codes

Z1030 – Z1038, Z1200 – Z1212, or CPT-4 series 10000 – 69999) and their corresponding modifiers, are billed on the same claim when multiple surgeries are performed on the same date of service for the same recipient.

ub spec op 7


Identical Services Identical services billed for the same date of service are considered Billed for the Same duplicate billings. Only one service will be reimbursed. Date of Service

When a service is legitimately rendered more than once on the same date of the service (before and after X-rays, glucose tolerance testing, ova and parasite tests, etc.), providers must include documentation with the claim explaining why the service was rendered more than once. This information may be entered in the Remarks field (Box 80) or on an attachment to the claim. When billing electronically, enter the statement in the Remarks area. Note: A statement indicating “this service is not a duplicate” is not

sufficient to clarify why the service was rendered more than once.

Providers who receive a denial for duplicate services may submit a Claims Inquiry Form (CIF) for claim reconsideration. The CIF must include documentation or a statement in the Remarks area explaining why the service was rendered more than once.

ub sub UB-04 Submission and Timeliness Instructions 1

2 – UB-04 Submission and Timeliness Instructions December 2009

This section provides procedures and guidelines for claim submission and timeliness (except for Local Educational Agency [LEA] providers). For specific claim completion instructions, refer to the UB-04 Completion sections of this manual. Where to Submit Claims Inpatient: Outpatient: HP Enterprise Services HP Enterprise Services P.O. Box 15500 P.O. Box 15600 Sacramento, CA 95852-1500 Sacramento, CA 95852-1600 Six-Month Billing Limit Original (or initial) Medi-Cal claims must be received by the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) within six months following the month in which services were rendered.

This requirement is referred to as the six-month billing limit. For example, if services are provided on April 15, the claim must be received by the FI prior to October 31 to avoid payment reduction or denial for late billing. Delay Reasons Exceptions to the six-month billing limit can be made if the reason for

the late billing is one of the delay reasons allowed by regulations. Delay reasons also have time limits. See Figure 2 for a list of delay reason codes and required documentation.

ub sub 2

2 – UB-04 Submission and Timeliness Instructions November 2007

Late Billing Instructions Follow the steps below to bill a late claim that meets one of the approved exception reasons:

• Enter the appropriate delay reason code (1, 3 – 7, 10, 11 or 15) in the Unlabeled field (Box 37A) of the claim.

• Complete the Remarks field (Box 80) of the claim with the information required for delay reason codes 1 (descriptions 1 and

2) and 3 – 6.

• Attach substantive documentation to justify late submittal of the claim for delay reason codes 1 (description 3), 7, 10, 11 and 15. The Delay Reasons chart on the following pages describes the documentation required for each delay reason.

Note: Delay reason codes 1 (description 3), 7, 10, 11 (description 1) and 15 require attachments to be sent. These codes require attachments that some electronic billing formats do not accommodate. Claims requiring attachments must be hard copy billed or electronically billed using the ASC 12N 837 v.4010A1 claim format with correlating attachments submitted with the Medi-Cal Claim Attachment Control Form (ACF). For more information regarding attachment submissions, refer to the Billing Instructions of the 837 Version 4010A1 Health Care Claim Companion Guide on the Medi-Cal Web site at www.medi-cal.ca.gov.

Providers whose circumstances fall outside of established delay

reason descriptions for claims submitted during the seventh through twelfth month after the month of service should enter an “11” in the Condition Codes field (Boxes 18 – 24) of the claim.

Documentation Requirements Documentation justifying the delay reason must be attached to the

claim to receive full payment. Providers billing with delay reason code “11” without an attachment will receive reimbursement at a reduced rate or will be denied. Refer to “Reimbursement Reduced for Late Claims” in the Claim Submission and Timeliness Overview section of the Part 1 manual for more information.

ub sub 3


Claims Over The DHCS FI reviews all original claims delayed over one year from One Year Old the month of service due to court decisions, fair hearing decisions, county administrative errors in determining recipient eligibility, reversal of decisions on appealed Treatment Authorization Requests (TARs),

Medicare/Other Health Coverage delays or other circumstances beyond the provider’s control. Claims submitted more than 12 months from the month of service must always use delay reason code “10”, and must be billed hard copy with the appropriate attachments as listed in Figure 1 on a following page. These claims must be submitted to the FI at the following special address:

HP Enterprise Services Over-One-Year Claims Unit P.O. Box 13029 Sacramento, CA 95813-4029

Note: Providers will receive a Remittance Advice Details (RAD)

message indicating the status of their claim.

ub sub 4


Claims submitted to the Over-One-Year Claims Unit must include a copy of the recipient’s proof of eligibility and one of the following documents with the late claim.

Cause of Delay

Delay Reason Code Documentation Needed

Retroactive SSI/SSP 10 Copy of the original County Letter of Authorization (LOA) form (MC-180) signed by an official of the county.

Court order 10 Same as previous

State or administrative hearing

10 Same as previous

County error 10 Same as previous

Department of Health Care Services (DHCS) approval

10 Same as previous

Reversal of decision on appealed Treatment Authorization Request (TAR)

10 Copy of the TAR, copy of the DHCS letter or court order reversing the TAR denial, and an explanation of the circumstances in the Remarks field (Box 80) of the claim.

Medicare/Other Health Coverage

10 Copy of the Other Health Coverage Explanation of Benefits and an explanation of the circumstances in the Remarks field (Box 80) of the claim.

Figure 1. Over-One-Year Billing Exceptions.

Note: Providers must bill Medicare or the Other Health Coverage within one year of the month of service to meet Medi-Cal timeliness requirements.

Claims Inquiry Form The same follow-up guidelines apply to over-one-year-old and original

claims when submitting a Claims Inquiry Form (CIF). Refer to the CIF Submission and Timeliness Instructions section of this manual for more information.

ub sub 5


DELAY REASONS Reason Code Description Documentation Needed 1 (1) ° Proof of eligibility unknown or

unavailable. (1) In the Remarks field (Box 80), enter month,

day, and year when proof of eligibility (or retroactive eligibility) was received, for example, “Proof of eligibility received March 15, 2002.”

(2) * For obstetrical providers who are unable to bill for global services when patients leave their care before delivery.

(2) In the Remarks field (Box 80), enter the date that the patient left obstetrical care.

(3) ‡ For Share of Cost reimbursement processing.

(3) Attach a Share of Cost Medi-Cal Provider Letter (MC 1054) for SOC reimbursement processing.

3 * TAR approval days. In the Remarks field (Box 80) enter only the approval date of the TAR or CCS authorization.

4 * Delay by DHCS in certifying providers. In the Remarks field (Box 80), enter a statement indicating the date of certification.

5 * Delay in supplying billing forms. In the Remarks field (Box 80) enter a statement indicating the date billing forms were requested and date received.

6 * Delay in delivery of custom-made eye appliances.

In the Remarks field (Box 80) enter a statement explaining why the appliance was not previously delivered to the recipient.

7 * + ‡ Third party processing delay. (1) Medicare/Other Health Coverage.

With the Medi-Cal claim, submit a copy of the Other Health Coverage Explanation of Benefits or Remittance Advice showing payment or denial.

(2) ♣ Charpentier rebill claims. Submit a copy of the Remittance Advice Details (RAD) for the original crossover claim.

Deadlines for Claim Receipt: * Claims related to these circumstances must be received by the FI no later than one year from

the month of service. ‡ Must be hard copy billed using the UB-04 claim or electronically billed using the ASC X12N 837

v.4010A1 claim format with correlating attachments submitted with the Medi-Cal Claim Attachment Control Form (ACF).

♣ Charpentier rebill claims must be received within six months of Medi-Cal RAD date for the original crossover claim.

+ Claims related to these circumstances, together with the Medicare or Other Health Coverage Explanation of Benefits or Remittance Advice or denial letter, must be received by the Other Health Coverage carrier no later than 12 months after the month of service and by the FI within 60 days of the other health carrier’s resolution (payment/denial).

° Claims related to this circumstance must be received by the FI no later than 60 days after the date indicated on the claim that proof of eligibility is received by the provider. Proof of eligibility must be obtained no later than one year after the month in which service was rendered.

Figure 2. Delay Reasons.

ub sub 6


DELAY REASONS (continued) Reason

Code Description Documentation Needed 10 ++ ‡ Administrative delay in prior approval

process. Submit recipient proof of eligibility and the court order or fair hearing decision.

(1) Decisions/appeals. (2) Delay or error in the certification or

determination of Medi-Cal eligibility. Submit a copy of the original County Letter of Authorization (LOA) form (MC-180) signed by an official of the county. (In the Remarks field (Box 80), indicate date received from the recipient.)

(3) Update of a TAR beyond the 12-month limit.

Submit recipient proof of eligibility and copy of the updated TAR.

(4) Circumstances beyond the provider’s control as determined by DHCS.

Submit recipient proof of eligibility with either a copy of DHCS approval or a copy of the Other Health Coverage (including Medicare) proof of payment or denial. Note: Claims submitted under this condition

must have been billed to the OHC carrier within one year of the month of service.

11 Other (1) ** ‡ Theft, sabotage (attachment

required). (2) † After six months, no reason. (3) * Late charges.

Attach documentation justifying the delay reason. Inpatient providers must use claim frequency code 5 when adding a new ancillary code to indicate a hospital stay that was billed when the original claim was submitted.

15 * ‡ Natural disaster. Attach a letter on provider letterhead describing the circumstances and date of occurrence. The letter must be signed by the provider or provider’s designee.

Deadlines for Claim Receipt: * Claims related to these circumstances must be received by the FI no later than one year from the

month of service. ** Claims related to these circumstances must be received by the Department of Health Care

Services Payment Systems Division, Provider Services Section; MS 4712; 3215 Prospect Park Drive, Room 160; Rancho Cordova, CA 95670 no later than one year from the month of service.

++ Claims related to these circumstances must be received by the FI, Over-One-Year Claims Unit; P.O. Box 13029; Sacramento, CA 95813-4029 no later than 60 days after the date of resolution of the circumstance which caused the billing delay.

‡ Must be hard copy billed using the UB-04 claim or electronically billed using the ASC X12N 837 v.4010A1 claim format with correlating attachments submitted with the Medi-Cal Claim Attachment Control Form (ACF).

† Claims related to these circumstances will be reimbursed at a reduced rate according to the date the claim was received by the FI. Refer to “Reimbursement for Late Claims” in the Claim Submission and Timeliness section in the Part 1 manual.

Figure 2 (continued). Delay Reasons.

ub tips op UB-04 Tips for Billing: Outpatient Services 1

2 – UB-04 Tips for Billing: Outpatient Services Outpatient Services 418 July 2009

This section describes UB-04 claim fields that must be completed accurately and completely in order to avoid claim suspense or denial. Tips below are designed to supplement instructions in the UB-04 Completion: Outpatient Services section in this manual.

Common Billing Errors Field Description Error

6 Statement Covers Period (From-Through)

Entering information in this field, which is not required by Medi-Cal for outpatient claims. Billing Tip: For outpatient “From-Through” billing instructions, see the UB-04 Special Billing Instructions for Outpatient Services section in this manual.

18 – 24 Condition Codes Omitting codes or entering a Medi-Cal local billing limit exception code (A, 1 – 9). Billing Tip: The delay reason code is entered in the Unlabeled field (Box 37A) of the claim. Billing Tip: Enter codes in numeric-alpha order. For example, 80, 82, X1.

39 – 41 Value Codes and Amount (Patient’s Share of Cost)

Missing value code information. Entering only the value code and not the amount. Entering only the amount and not the value code. Billing Tip: Value codes and amounts should be entered from left to right, top to bottom in numeric-alpha sequence starting with the lowest value. Value code information is required for Medicare crossovers.

43 Description Omitting individual dates of service required after entering description of services rendered. Billing Tip: The description must identify the particular service code indicated in the HCPCS/Rate field (Box 44). For more information, refer to the specific policy section in this manual or the CPT-4 code book. Omitting the product ID qualifier and NDC for physician-administered drugs. Incorrect entry of optional unit of measure and numeric quantity. Billing Tip: Check instructions in the Physician-Administered Drugs – NDC: UB-04 Billing Instructions and UB-04 Completion: Outpatient Services sections of this manual for the appropriate product ID qualifier, NDC, unit of measure qualifier and numeric quantity, and instructions on entering this information. Unit of measure and numeric quantity are optional; however, entering the NDC quantity in the proper format is crucial to the correct payment for a billed NDC.

ub tips op 2

2 – UB-04 Tips for Billing: Outpatient Services Outpatient Services 429 June 2010

Field Description Error

44 HCPCS/Rate/HIPPS Code

Entering incorrect code for provider type, omitting procedure code or omitting modifier(s). Billing Tip: Revenue codes are increasingly required on outpatient claims, including:

• Adult Day Health Care (ADHC) (all codes) • Home and Community-Based Waiver Services (select

codes) • Hospice (room and board only) • EAPC (all codes)

EAPC claims must include the required revenue code in the Revenue Code field (Box 42) and the HCPCS code, immediately followed by the appropriate modifier, in the HCPCS/Rate field (Box 44). Claims submitted without all three will be denied.

For Section 340B providers submitting claims for physician administered drugs: omitting the modifier UD. Billing Tip: Check instructions in the UB-04 Completion: Outpatient Services section of this manual for the appropriate location of modifier UD for Section 340B drugs on the UB-04.

46 Service Units Entering the wrong service units as required by the billing code. Billing Tip: Although this is a seven-digit field, Medi-Cal only allows two digits in this field.

50 A – C Payer Name

Entering a Place of Service code. Billing Tip: Enter the two-digit facility type and one-character frequency code as specified in the National Uniform Billing Data Element Specifications manual in the Type of Bill field (Box 4). Missing all payer information. Billing Tip: Be sure to enter the “O/P” indicator.

54 A – B Prior Payments (Other Coverage)

Missing prior payment or Other Health Coverage not indicated. Billing Tip: Be sure to enter the patient’s other health insurance payment. Do not enter Medicare payments in this box.

56

NPI Missing or incorrect NPI number. Billing Tip: Enter the NPI.

ub tips op 3

2 – UB-04 Tips for Billing: Outpatient Services Outpatient Services 414 March 2009

Field Description Error

60 A – C Insured’s Unique ID Missing the recipient’s Medi-Cal ID number. Billing Tip: Verify that the recipient is eligible for the services rendered by using the POS network or telephone AEVS. Do not enter the Medicare ID number.

63 Treatment Authorization Codes

Entering EVC number instead of the TAR number. Billing Tip: The EVC number is only for verifying eligibility. Do not enter this number on the claim.

80 Remarks Reducing font size or abbreviating terminology to fit in the field. Billing Tip: If additional information cannot be completely entered in this field, attach the additional information to the claim. Reducing font size and abbreviating terminology may result in scanning difficulties and/or medical review denials.

ub tips op 4

2 – UB-04 Tips for Billing: Outpatient Services Outpatient Services 422 November 2009

Field Completion Reminders Providers should remember the following when completing the claim form.

• Submit separate claims for outpatient services. Do not combine

inpatient and outpatient services on the same claim.

• Enter the provider name. Enter the address, without a comma between the city and state, and a nine-digit ZIP code, without a hyphen, in the upper left corner of the form (Box 1). A telephone number is optional in this field.

Note: The nine-digit ZIP code entered in this box must match the providing biller’s nine-digit ZIP code on file for claims to be reimbursed correctly.

• The upper middle Unlabeled field (Box 2) is reserved for the Department of Health Care Services (DHCS) Fiscal Intermediary (FI) use only. Type only in areas of the claim form designated as fields. Do not type in undesignated white space.

• Enter the three-digit facility type code in the Type of Bill field (Box 4).

• Enter the service date for each detail line.

• To strike out a claim line with incorrect information, draw a line through the entire detail line from the left border of the Revenue Code field (Box 42) to the right border of the Unlabeled field (Box 49). Enter the correct billing information on another detail line. Be sure to use only a blue or black ballpoint pen. Felt-tip pens are unacceptable.

• Include the individual dates of service after entering a description of services rendered in the Description field (Box 43) for “from-through” billing.

• Enter “001” (Total Charges) in field 42, line 23, and enter the total amount in field 47, line 23.

• Enter the provider’s NPI in the NPI field (Box 56). For atypical providers who do not have an NPI, enter the provider number in the Other Provider ID field (Box 57).

ub tips op 5

2 – UB-04 Tips for Billing: Outpatient Services Outpatient Services 414 March 2009

Paper Claim Form The following paper claim form requirements and standard billing Requirements procedures can speed claim processing and prevent delays. Before

submitting claims, check to see that:

• The UB-04 claim is printed with “drop-out” ink and that the form meets National Uniform Billing Committee (NUBC) standards.

• The original claim is submitted. Carbon copies or photocopies, computer-generated claim form facsimiles or claim forms created on laser printers are not acceptable.

• Individual claim forms are separated. Each claim is processed separately. Do not staple individual claims together. Stapling individual claims together indicates the second claim is an “attachment,” not an original claim to be processed separately.

• All perforated sides are removed. For accurate scanning, be sure to leave a ¼-inch border on the left and right side of the form after removing the perforated sides.

• Information is typed within the designated area of the field. Be sure the type falls completely within the text space and is properly aligned with corresponding information. If using a DOT matrix printer, do not use “draft mode.” The characters do not have enough distinction and clarity for the optical character reader to accurately determine the contents.

• All dates are entered without slashes. Do not use punctuation, such as decimal point (.), dollar sign ($), positive (+) or negative (-) symbol when entering amounts.

• Attachments are taped to an 8½ x 11-inch sheet of paper with non-glare tape. Do not use original claims as attachments.

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