Medi-Cal Update – General Medicine
October 12, 2020- CPT Code for COVID-19 Testing Exempt from AB 97 10 Percent Payment Reduction Effective for dates of service on or after June 25, 2020, the American Medical Association created CPT® code 87426 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)]) for reporting antigen testing of patients suspected of being infected with the coronavirus disease 2019 (COVID-19). Additionally, the Department of Health Care Services (DHCS) is establishing the reimbursement rate at 100 percent of the Medicare rate for the new code. It is exempt from the ten percent payment reductions in Welfare and Institutions Code (W&I Code) Section 14105.192. Upon expiration of the public health emergency or national emergency, this rate will be amended to correspond with the clinical laboratory services methodology in W&I Code Section 14105.22, including the application of the Assembly Bill 97 (AB 97) payment reduction. An erroneous payment correction (EPC) will be implemented to reprocess the affected claims.|
- Effective for dates of service on or after June 25, 2020, CPT® code 87426 (Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) is now a Clinical Laboratory Improvement Amendments (CLIA)-waived test. This code is intended for use as the industry standard for accurate reporting and tracking of antigen tests using immunofluorescent or immunochromatographic technique for the detection of biomolecules produced by coronavirus disease 2019 (COVID-19). It is a Medi-Cal benefit.
- CPT Codes 86408 and 86409 for COVID-19 Testing are Medi-Cal Benefits Effective for dates of service on or after August 10, 2020, CPT® codes 86408 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; screen) and 86409 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; titer) for coronavirus disease 2019 (COVID-19) are now Medi-Cal benefits. Codes 86408 and 86409 do not have any gender or age restrictions; have a frequency limit of one per day, any provider, per patient; and may be billed with any ICD-10-CM codes.
- New Benefits to Aid Targeted Genomic Sequence Analysis Effective for dates of service on or after October 1, 2020, CPT® code 81445 (targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5–50 genes) is now a once-in-a-lifetime Medi-Cal benefit that requires a valid Treatment Authorization Request (TAR). CPT code 81455 (targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes) now has updated TAR requirements. TAR requirements for both services now delineate between Somatic and Germline testing, and either Somatic or Germline testing may be approved if the test is approved by the U.S. Food and Drug Administration (FDA) as a Companion Diagnostic Device and the decision for additional treatment is contingent on the test results. 10. TAR Criteria Updated for CPT Code 81404 Effective for dates of service on or after October 1, 2020, coverage for CPT® code 81404 (molecular pathology procedure, Level 5) is limited to the listed services including VHL (von Hippel-Lindau tumor suppressor), full gene sequence. Reimbursement for a VHL test using code 81404 requires an approved Treatment Authorization Request (TAR) and documented clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome. 12. Select Clinical Laboratory Rates Adjusted to 80 Percent of Medicare Rates Effective retroactively for dates of service on or after April 1, 2019, rates for select clinical laboratory or laboratory services are adjusted to 80 percent of the lowest maximum allowance established by the federal Medicare program for the same or similar services in accordance with Welfare and Institutions Code (W&I Code), Section 14105.22. Providers may refer to the Medi-Cal Rates page on the Medi-Cal Provider website for the rates. No action is required of providers. An Erroneous Payment Correction (EPC) will be initiated to automatically correct reimbursement, as appropriate, for claims already submitted.
- TAR Criteria Updated for CPT Code 81404 Effective for dates of service on or after October 1, 2020, coverage for CPT® code 81404 (molecular pathology procedure, Level 5) is limited to the listed services including VHL (von Hippel-Lindau tumor suppressor), full gene sequence. Reimbursement for a VHL test using code 81404 requires an approved Treatment Authorization Request (TAR) and documented clinical features suspicious for, or requires the service as a diagnostic test for von Hippel-Lindau syndrome.
- Select Clinical Laboratory Rates Adjusted to 80 Percent of Medicare Rates Effective retroactively for dates of service on or after April 1, 2019, rates for select clinical laboratory or laboratory services are adjusted to 80 percent of the lowest maximum allowance established by the federal Medicare program for the same or similar services in accordance with Welfare and Institutions Code (W&I Code), Section 14105.22. Providers may refer to the Medi-Cal Rates page on the Medi-Cal Provider website for the rates. No action is required of providers. An Erroneous Payment Correction (EPC) will be initiated to automatically correct reimbursement, as appropriate, for claims already submitted.