CHIA User Workgroup Meeting - May 24, 2022
This meeting covers updates on APCD Release, Case Mix Projections, Website Updates, COVID-19 Vaccine Status, and more. Data requests and timelines are detailed for CY 2020 and FY21 releases. Website updates provide information on data product development. User engagement and support are key focuses.
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Presentation Transcript
Drug Medi-Cal Organized Delivery System Claiming Technical Assistance Webinar for Counties February 2, 2017 3/15/2025 1
Overview of Presentation DMC-ODS Healthcare Common Procedure Coding System DMC Billing Manual & New DMC-ODS Waiver Chapter Questions and Discussion 3/15/2025 2
DMC-ODS Healthcare Common Procedure Coding System (HCPCS) 3/15/2025 3
Information Notice 17-002 DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) AND MODIFIERS Supersedes IN 16-057 http://www.dhcs.ca.gov/formsandpubs/Pages/2017- MHSUDS-Information-Notices.aspx 3/15/2025 4
DMC ODS HCPCS and Modifiers Once a county has opted-in to the DMC-ODS Pilot, the old codes and modifiers will not be sufficient to get the claim approved in the Short-Doyle Medi-Cal system. New combinations of HCPCS codes and modifiers will need to be submitted on the 837P claim file. 3/15/2025 5
HCPCS Modifiers HG Opioid addiction treatment program We will continue to use the HG modifier on the OTP/NTP claims, unless the claim is for Recovery Services. HD Pregnant/parenting women's program We will continue to use the HD modifier to identify perinatal and post-partum women s services. 3/15/2025 6
HCPCS Modifiers (cont.) HA Child/adolescent program We have included the HA modifier to distinguish between adult and child/youth services in the DMC-ODS. Any beneficiary under the age of 21 will need to have this modifier on every claim to assure correct claim adjudication. 3/15/2025 7
U Codes Level of Care U1 3.1 RES U2 3.3 RES U3 3.5 RES U4 1-WM U5 2-WM U6 Recovery Services U7 - ODF U8 - IOT U9 3.2-WM UA OTP/NTP UB Partial Hospitalization 3/15/2025 8
Recovery Services Recovery Services have some unique characteristics. Recovery Services are available for each DMC-ODS level of care. Recovery Services are available to beneficiaries that have completed treatment. Recovery Services cannot be claimed in combination with any other treatment service. 3/15/2025 9
Recovery Services (cont.) The components of Recovery Services include: Individual counseling H0004/U6 Group counseling H0005/U6 Case management H0006/U6 Recovery monitoring/substance abuse assistance T1012/U6 3/15/2025 10
National Drug Codes (NDC) Medication Assisted Treatment (MAT) with HCPCS S5000 and S5001 will need to use the NDC for the medication that is administered. OTP/NTP MAT is required to provide buprenorphine, disulfiram, and naloxone to beneficiaries. S5000/S5001 with the UA modifier and the correct NDC will be necessary for correct claim adjudication. 3/15/2025 11
National Drug Codes (NDC) (cont) Non-OTP/NTP MAT is optional for counties that choose to provide additional medications to beneficiaries. The ODS county will set rates for these non-OTP/NTP medications. S5000/S5001 with the appropriate U code modifier and the correct NDC will be necessary for correct claim adjudication. 3/15/2025 12
Same Day Billing DMC-ODS Same Day Billing rules (Information Notice 16-007) have eliminated the need for the Multiple Billing Override code. Note: Same Day Billing in more than one level of care will be restricted to combinations with OTP/NTP to allow for cases where methadone dosing is part of the necessary treatment for any beneficiary in any other level of care. 3/15/2025 13
Short Doyle Medi-Cal Claiming In order to submit correctly coded claims for the DMC-ODS services beginning on the Go Live date and forward, each DMC-ODS county will need to use the new HCPCS code and modifier combinations that have been identified in IN 17-002. 3/15/2025 14
DMC Billing Manual & New DMC-ODS Waiver Chapter 3/15/2025 15
Overview The purpose of the DMC Billing Manual is to provide counties and direct providers with information on how to submit a claim for reimbursement for DMC services rendered. The DMC-ODS waiver chapter provides direction to counties that have an executed Intergovernmental Agreement with DHCS to administer waiver services. Updated DMC Billing Manual posted on the DHCS website: http://www.dhcs.ca.gov/formsandpubs/Documents/DMC_Bill ing_Manual_2017.pdf 3/15/2025 16
Overview (cont.) Most federal and state regulations that pertain to DMC billing for regular state plan services are still applicable in the DMC-ODS. Only counties can opt-in to the waiver. Detailed guidance for DMC-ODS billing is outlined in Chapter 6 and related Information Notices. 3/15/2025 17
New DMC-ODS Services Case Management Physician Consultation Withdrawal Management Medication Assisted Treatment Partial Hospitalization 3/15/2025 18
Services Comparison Regular State Plan Services Waiver Services Outpatient, intensive outpatient, residential, and narcotic treatment are available Residential treatment is an optional service - 16-bed capacity limit - Perinatal beneficiaries only County must provide outpatient, intensive outpatient, residential, and narcotic treatment Residential treatment includes several levels (3.1, 3.3, 3.5). County must provide at least one level initially and all levels with 3 years - no bed capacity limit - all populations allowed (men, youth, peri or non-peri) - provider's level designated by SUD Compliance Methadone is the only medication assisted treatment (MAT), available only in narcotic treatment programs (NTPs) Additional MAT available in NTP programs and non-NTP programs: - NTP MAT: Buprenorphine, Naloxone, Disulfiram - non-NTP MAT: county identifies those they will provide Withdrawal management: only available as fee for service Withdrawal management includes several levels (1, 2, 3.2). County must provide at least one level County must provide case management, physician consultation, and recovery services Partial hospitalization and additional MAT are optional services Case management, physician consultation, recovery services are not allowable services Partial hospitilization and additional medication assisted treatment (MAT) are not allowable services Rates/Units of Service/Billing Rates are set by DHCS (state maximum allowance - SMA) Rates/Units of Service/Billing (Interim) rates are set by the county, approved by DHCS. SMA does not apply. Group and individual counseling will have same rate UOS = 15 minutes for all services, except UOS = daily for partial hospitalization, withdrawal management, residential; and UOS = 10 minutes for NTP counseling Separate rates for ODF individual and ODF group counseling Units of service (UOS) vary depending on service (i.e., ODF group is 90 minutes; ODF individual is 50 minutes) No formula used to determine group minutes per beneficiary Fractional units of service are not allowed; county must pro-rate the cost Multiple billing override code is needed for multiple services in one day National Drug Code (NDC) not required on 837P Formula used to determine group counseling minutes for each beneficiary Fractional units are allowed. No multiple billing override code, but some services are not allowed on the same day (see lockout table) NDC is required on 837P 3/15/2025 19
Questions and Discussion For optimal sound quality, please ensure that you are dialed-in using your phone and that you have inputted your audio PIN. 3/15/2025 20
California Department of Health Care Services Karen Baylor, PhD, Deputy Director, MHSUDS, DHCS Marlies Perez, Division Chief, MHSUDS, DHCS Don Braeger, Division Chief, MHSUDS, DHCS For More Information: http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi- Cal-Organized-Delivery-System.aspx 3/15/2025 21
Harbage Consulting Don Kingdon, PhD, Principal, Behavioral Health Integration don@harbageconsulting.com Molly Brassil, MSW, Director, Behavioral Health Integration molly@harbageconsulting.com Courtney Kashiwagi, MPH, Senior Policy Consultant courtney@harbageconsulting.com Erynne Jones, MPH, Senior Policy Consultant erynne@harbageconsulting.com 3/15/2025 22
DMC-ODS Resources For additional information, please see the DMC-ODS Frequently Asked Questions posted the DHCS website: http://www.dhcs.ca.gov/provgovpart/Pa ges/Fact-Sheets-and-FAQs.aspx? For questions, please contact dmcodswaiver@dhcs.ca.gov 3/15/2025 23
