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Psychology Billing Invoice - DOC

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					                                                                           Section Titles/Headings Index 1
Section Titles/Headings Index alphabetically lists section titles and boldfaced headings in the Part 1 and all
Part 2 provider manuals. Refer to the Forms Index for an alphabetical list of forms in the Part 1 and all Part 2
provider manuals. The page numbering system will guide you to information in these manuals. Refer to How to
125

Use the Indexes and Glossary in this manual for detailed information. The page numbering system includes:
                                                 Manual part number (P1 or P2)
                                                 Provider identifier (see index footer)
                                                 Locator key (abbreviated form of the section title)
                                                 Page number

A                                                                   Acupuncture Services: Billing Codes and
Abortions, P2: CAH MS abort                                          Reimbursement Rates, P2: ACU REH acu cd
   abortion-related supplies and services: 60-day frequency            codes and rates, 1
     limit, 6                                                       Acupuncture Services Billing Example: CMS-1500,
   abortion services, 1                                              P2: ACU acu exc
   cervical dilation with hygroscopic agents, 3                        billing tips, 1
   dilation and curettage/dilation and evacuation, 4–5                 multiple acupuncture visits, 2–3
   elective abortion: incidental or preliminary                     Acupuncture Services Billing Example: UB-04,
      services, 1–2                                                  P2: REH acu exu
   medical abortion, 7                                                 billing tips, 1
   simultaneous sterilization and abortion: restricted                 multiple acupuncture visits, 2–3
     conditions, 5                                                  Administrative Days, P2: IP admin
   surgical pathology gross and microscopic examination of             administrative days, 1
     materials, 1                                                      ancillary services not reimbursable with administrative
   ultrasound, 3–4                                                       days, 2–4
Accommodation Codes for Long Term Care, P2: LTC                        ancillary services reimbursable with administrative
  accom cd ltc, 1                                                        days, 2
Acupuncture Services, P2: ACU REH acu                               Admissions and Discharges, P2: LTC admis
   authorization, 2                                                    admission procedures, 1–2
   claim information, 3                                                discharge procedures, 2
   eligibility requirements, 1                                         discharge to home, 10–11
   initial and subsequent visits, 2                                    long term care facility information for public assistance
   non-covered services, 3                                              or Medi-Cal recipients (MC 171A), 3
   prescription requirements, 2                                        Medi-Cal Long Term Care Facility Admission and
   program coverage, 1                                                  Discharge Form (MC 171), 1
                                                                       ordering forms, 3–9
                                                                       routine or standing orders–hospitals and skilled nursing
                                                                        facilities, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
2 Section Titles/Headings Index
Adult Day Health Care (ADHC) Centers, P2: ADU adu                   Adult Day Health Care (ADHC) Centers: Tracking Costs
   billing carry-over days, 10                                       for Reimbursement Purposes, P2: ADU adu track
   billing procedures, 12                                              completion of cost report form, 43
   definitions*, 2                                                     cost reporting: service log requirements, 2
   eligible recipients, 7                                              definitions, 4–11
   personal health care provider, 6                                    mental health services, 26–32
   program requirements, 4                                             registered dietitian services, 33–38
   provider assistance, 3                                              separately billable services, 1
   reimbursement: FQHCs and RHCs, 11                                   separately billable therapy services, 12–25
   reimbursement: health care plans (HCPs), 11                         transportation services, 39–43
   reimbursement: Other Health Coverage/Medicare, 11                AEVS: General Instructions, P1: aev gen
Adult Day Health Care (ADHC) Centers: Billing Codes                     Accessing Telephone AEVS
 and Reimbursement Rates, P2: ADU adu cd                                   "bypass" procedures, 5–6
   ADHC codes and rates, 1                                                 documenting eligibility information, 4
   FQHC codes, 1                                                           error limits, 3
Adult Day Health Care (ADHC) Centers Billing                               hours of operation, 4
 Examples, P2: ADU adu ex                                                  inquiry limitations, 5
   ADHC regular days: "single-line" billing, 2–3                           time limit, 3
   billing tips, 1                                                      Entering Alphabetic Data
Adult Day Health Care (ADHC) Centers: TAR,                                 14-digit Medi-Cal ID, 8
 Individual Plan of Care (IPC) and History and Physical                    9-digit ID number, 8
  Form Completion P2: ADU adu tar ipc                                      alphabetic codes "Q" and "Z", 8
       carry over days, 9–10                                               HCPCS codes, 8
       H&P signature page & IPC form accompany TAR, 3                      list of alphabetic codes, 9
       incomplete submissions: resubmission turnaround                     two-digit code, 7
         document (RTD), 5                                              General Information
       lapsed (expired) TARs, 6                                            BIC card, 2
       number of days, 7                                                   edit conditions, 1
       request for additional therapy services, 11                         Eligibility Verification Confirmation number, 2
       request for increase in days of service                             HAP card, 2
         (change TAR), 5–6                                                 transactions available, 1
       TAR completion and form example, 4                           AEVS: Other Health Coverage (OHC) Carrier Codes,
       state law, 2                                                  P1: aev ohc car
       transmittal form (MC 3020), 5                                    * access on the Internet at www.medi-cal.ca.gov
       transportation, 11
   Individual Plan of Care (IPC)
       completion and form example, 13
       explanation of form items, 14–31
       submitting with TAR, 13




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                           Section Titles/Headings Index 3
AEVS: Transactions, P1: aev trn                                     Aid Codes Master Chart, P1: aid codes 1 – 15
  General Information                                               AIDS Waiver Agency Directory, P2: AID aid 1–3
      eligibility message types, 3–4                                AIDS Waiver Program, P2: AID aids
      Provider Identification Number, 1                                Client Information
      transaction menu, 1–3                                                aid paid pending, fair hearing requirements, 9
  Medi-Service Reservation or Reversal                                     disenrollment, 6
      transaction menu, 10–13                                              eligibility, 2–3
  Share of Cost Clearance or Reversal                                      enrollment limits, 5
      transaction menu, 4–9                                                enrollment process, 4
AEVS: Transactions–SOFP, P1: aev trn sofp                                  ineligibility/discontinuance and right to state hearing,
  Client Activation: BIC or HAP Identification Card                          7–8
      activation instructions, 2–4                                         participation: form MCWP1, 4
  Client Update Transaction                                                transfer between waiver programs, 5
      update instructions, 14–16                                       Introduction
  Deactivation Transaction                                                 background, 1
      deactivation instructions, 11–13                                 Provider Information
  General Information                                                      waiver agencies, 10
      AEVS options for SOFP, 2                                             waiver agency payment, 10–11
      confidentiality, 1                                               RAD Codes
      Health Access Programs State-Only Family Planning                    common denial codes and messages, 23–24
        Program Client Eligibility Certification form, 1
      SOFP-eligible providers, 1
  Inquiry Transaction
      inquiry instructions, 17–19
  Recertification Transaction
      activation instructions, 7–10
  SOFP Card Activation Transaction
      activation instructions, 4 – 7




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services     OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                        LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program         MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals       REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                        PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                    VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                     July 2011
4 Section Titles/Headings Index
AIDS Waiver Program, P2: AID aids (continued)                       Allergy Testing and Desensitization, P2: CAH GM allergy
   Special Billing Instructions                                        allergy injections and TAR requirements, 3
       billing examples, 22                                            allergy testing codes, 1
       claim waiver ID number, 21                                      antigen codes, 2–3
       facility type codes, 22                                         desensitization services: CPT-4 code 95115, 2
       "from-through" billing, 22                                      radioallergosorbent allergy testing, 1
       HIV diagnosis code 042, 22                                   Alternative Birthing Centers, P2: CAH MS altern
       waiver agencies enrollment procedures, 21                       CPT-4 codes, 1–2
   Waiver Services                                                     HCPCS codes, 3
       administrative expenses (HCPCS code T2025), 19               Ancillary Code s, P2: IP ancil cod
       attendant care (HCPCS code G0516), 14                           audiology ancillary codes, 1
       case management (HCPCS code 5130), 12                           ancillary codes, 2–8
       general information, 12                                         billing administrative days, 1
       homemaker services (HCPCS code S5130), 15                       blood gas studies, 1
       “specialized medical equipment and supplies” and                itemizing charges, 1
          physical adaptations to the home (HCPCS code                 OSHPD ancillary codes (for accounting purposes
               S5165, T2028, T2029), 16–17                               only), 1, 9–17
       non-emergency medical transportation (HCPCS code
       T2003), 18
       nutritional counseling (HCPCS code S9470), 19
       nutritional supplements/home delivered meals
         (HCPCS code S5170), 19–20
       psychotherapy counseling (HCPCS code
               90806,90846,90847), 14
       skilled nursing by RNs/LVNs (HCPCS codes
         G0154), 13
       specialized child care (HCPCS code T2026), 16
AIDS Waiver Program Billing Codes and Rates,
 P2: AID aids bil cd
   procedure codes/rate schedule, 1
AIDS Waiver Program Billing Examples,
 P2: AID aids bil ex
   AIDS Waiver Services: adult claim, 2–4
   AIDS Waiver Services: pediatric claim, 5–6
   billing tips, 1
AIDS Waiver Program Directory
   waiver agency locations, 1–3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 5
Anesthesia, P2: CAH MS anest                                        Anesthesia Billing Examples: UB-04, P2: CAH anest ub
   anesthesia modifiers chart, 19                                     add-on codes, 4
   anesthesia pump assembly and operation, 20                         anesthesia administered for less than five minutes, 2
   anesthesia risk/emergency modifiers, 22                            billing tips, 1
   anesthesia supervision, 22                                         split case, 6
   anesthesiologist present but not administering                     surgical clinic billing for anesthesia, room use and
    anesthesia, 10                                                      anesthesia-related supplies, 8
   billing anesthesia services, 1–5                                 Appeal Form Completion, P2: appeal form
   billing multiple anesthesia modifiers, 6                           Appeal Form (90-1), 1
   Certified Registered Nurse Anesthetist, 22                         completion, 7–9
   CRNA Anesthesia Modifiers Chart, 23–24                             FI acknowledgement of appeal, 3
   emergency anesthesia modifier: healthy patient, 17–18              explanation of form items, 5–6
   epidural opioid administration, 11–15                              judicial remedy: one-year limit, 3
   general anesthesia services guidelines:                            supporting documentation for appeals, 1–2
    medical necessity, 10                                             timeliness: 90-day deadline, 2
   nasal endoscopy: general anesthesia requirements, 23               where to submit appeals, 3
   normal, uncomplicated anesthesia modifiers, 8                    Appeal Process Overview, P1: appeal
  pelvic examination under anesthesia, 10                             appeal response letter, 2
   prone position or surgical field avoidance modifier, 8             FI acknowledgement of appeal, 2
   pulse oximetry: anesthesia guidelines, 20                          judicial remedy: one-year limit, 2
   separately reimburseable anesthesia services, 9                    preparing an appeal, 1
   services included in basic rate, 8                                 timeliness: 90-day deadline, 1
   split case for anesthesia services, 21–22                          where to submit appeals, 1
   supplies and drugs modifiers, 15–16
   surgical and obstetrical anesthesia, 6–7
Anesthesia Billing Examples: CMS – 1500,
 P2: MS anest cms
   add-on codes, 3
   billing tips, 1
   multiple anesthesia modifier: -ZG, 6
   split case, 4–5
   tubal ligation performed during a C-section, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
6 Section Titles/Headings Index
Audiological Services, P2: ADU AUD REH THP audio                    B
   auditory evoked potentials, 11                                   Blood and Blood Derivatives,
   authorization, 3                                                  P2: CAH DIA GM PH blood
   cochlear implantation (CI), 8–12                                    albumin, 11
   electronystagmography, 7                                            blood derivative Anti-Hemophilia Factors (AHF) VIIa,
   eligibility requirements, 1–2                                         VIII and IX, 1–3
   evoked response testing, 6–7                                        blood factors: billing for bleeding and clotting
   hearing aid evaluations, 4                                            disorders, 1
   impedance audiometry, 8                                             blood factors billing: pharmacists/non-pharmacists, 3–4
   initial and six-month evaluations, 4                                blood irradiation: blood banks, 11
   authorization, 3                                                    blood products and blood derivatives other than
   program coverage, 1                                                   blood factors, 8
   pure tone audiometry, 6                                             contract blood factors, 2
   tympanometry, 8                                                     designated blood donation, 1
   unlisted audiological services, 5                                   fresh frozen plasma, 8
   written referral requirements, 2                                    pheresis, 9–10
Audiological Services: Billing Codes and Reimbursement                 public health services covered entities, 4
 Rates, P2: ADU AUD REH THP audio cd                                Blood and Blood Derivatives Billing Examples:
   codes and rates, 1–3                                              CMS-1500, P2: GM PH blood cms
Audiological Services Billing Example: CMS-1500,                       billing tips, 1
 P2: AUD THP audio exc                                                 separate manufacturer's AHF blood factors on one
   audiological services, 2–3                                            claim line, 2–3
   billing tips, 1                                                     separate manufacturer's blood factors billed on two
Audiological Services Billing Example: UB-04,                            claim lines, 4–5
 P2: ADU REH audio exu                                              Blood and Blood Derivatives Billing Examples: UB-04,
   audiological services, 2–3                                        P2: CAH DIA blood ub
   billing tips, 1                                                     billing tips, 1
                                                                       separate manufacturer's blood factors on one
                                                                         claim line, 2
                                                                       separate manufacturer's blood factors on two
                                                                         claim lines, 5–6




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 7
                                                                    California Children's Services (CCS) Program Billing
C                                                                    Example: CMS-1500 for Vision Care,
California Children's Services (CCS) Program,                        P2: VC cal child bil cms vc
 P2: AUD CAH DIA DME GM HOM IP LEA MTR OAP                             billing tips, 1
 OB PH PSY REH THP VC cal child                                        important fields for CCS claim completion, 2
   CCS clients with Other Health Coverage (OHC), 5                     services authorized prior to July 1, 2004, and
   CCS-only clients, 5                                                   clients in Los Angeles, Orange and Sacramento
   organization, 2–4                                                     counties, 2–3
   program overview, 1                                              California Children's Services (CCS) Program Billing
California Children's Services (CCS) Program Approved                Example: Pharmacy Claim Forms,
 Hospitals, P2: AUD CAH DIA DME GM HOM IP LEA                        P2: PH cal child bil ph
 MTR OAP OB PH PSY REH THP VC cal child appr                           billing tips, 1
   applying for CCS approval, 2                                        CAL-POS, 3
   hospitals approved for CCS, 1–2                                     important fields for CCS claim completion, 2
California Children's Services (CCS) Program Billing,                  services authorized prior to July 1, 2004, and clients in
 P2: AUD CAH DIA DME GM HOM IP LEA MTR OAP                               Los Angeles, Orange and Sacramento counties, 3–4
 OB PH PSY REH THP VC cal child bil                                 California Children's Services (CCS) Program Billing
   billing exceptions, 1                                             Example: UB-04 Claim Form, P2: CAH DIA HOM IP
   billing overview, 1                                               LEA REH cal child bil ub
   claim submission and timeliness requirements, 2                     important fields for CCS claim completion, 2
   CMC billing, 2                                                      services authorized prior to July 1, 2004, and clients in
   Denti-Cal, 2                                                          Los Angeles, Orange and Sacramento counties, 2–3
California Children's Services (CCS) Program Billing                California Children's Services (CCS) Program
 Example: CMS-1500, P2: AUD DME GM MTR OAP                           Communication Disorder Centers,
 OB PH PSY THP cal child bil cms                                     P2: AUD cal child com
   billing tips, 1                                                     Communication Disorder Centers, 1–2
   important fields for CCS claim completion, 2                     California Children's Services (CCS) Program County
   services authorized prior to July 1, 2004, and clients in         Office Directory, P2: AUD CAH DIA DME GM
     Los Angeles, Orange and Sacramento counties, 2–3                HOM IP LEA MTR OAP OB PH PSY REH THP
                                                                     VC cal child county CCS county office directory, 1–11




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
8 Section Titles/Headings Index
California Children's Services (CCS) Program                        California Children's Services (CCS) Program
 Eligibility, P2: AUD CAH DIA DME GM HOM IP                          Provider Paneling, P2: AUD CAH DIA
 LEA MTR OAP OB PH PSY REH THP VC cal child elig                     DME GM HOM IP LEA MTR OAP OB PH PSY
   Benefits Identification Card (BIC), 2                             REH THP VC cal child panel (continued)
   eligibility period, 2                                               physical therapist requirements, 9
   eligibility requirements, 1                                         physician paneling categories, 3
   medical eligibility criteria, 3–7                                   physician requirements, 5
California Children's Services (CCS) Program Medical                   podiatrist requirements, 7
 Therapy Program, P2: AUD CAH DIA DME GM                               preferred provider status for physicians applying
 HOM IP LEA MTR OAP OB PH PSY                                            for Medi-Cal enrollment, 4
 REH THP VC cal child med                                              provider paneling requirement, 1
   eligibility requirements, 1                                         providing a medical home, 6–7
   MTP medical eligibility criteria, 2                                 psychologist requirements, 10
   MTP referral, 2                                                     registered nurse requirements, 10
   program description, 1                                              respiratory care practitioner requirements, 11
California Children's Services (CCS) Program                           social worker requirements, 12
 Provider Paneling, P2: AUD CAH DIA                                    speech-language pathologist requirements, 12
 DME GM HOM IP LEA MTR OAP OB PH PSY
 REH THP VC cal child panel
   active Medi-Cal provider number required, 2
   audiologist requirements, 7
   dietitian requirements, 8
   family practice physician requirements, 5
   National Provider Identifier required, 2
   occupational therapist requirements, 8
   orthotist and prosthetist requiremetns, 8
   panel applications, 2
   pediatric nurse practitioner requirements, 9




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 9
California Children's Services (CCS) Program Service                California Children's Services (CCS) Program Referrals,
 Authorization Request (SAR), P2: AUD CAH                            P2: AUD CAH DIA DME GM HOM IP LEA MTR
 DIA DME GM HOM IP LEA MTR OAP OB PH PSY                             OAP OB PH PSY REH THP VC cal child ref
 REH THP VC cal child sar                                              CCS program application requirements, 3
   diagnostic laboratory SAR requirements, 5                           CCS referral, 1–2
   DME and medical supply SAR requirements, 9                       California Children's Services (CCS) Program
   home health agencies SAR requirements, 11                         Special Care Centers, P2: AUD CAH DIA
   inpatient SAR requirements, 5                                     DME GM HOM IP LEA MTR OAP OB PH
   pharmacy SAR requirements, 7                                      PSY REH THP VC cal child spec
   physical, occupational and speech therapy SAR                       SCC, 1
     requirements, 8                                                Cancer Detection Programs: Every Woman Counts,
   physician SAR requirements, 4–5                                   P2: CAH GM OB can detect
   SAR overview, 1                                                     approved procedures, 16–42
   Service Code Grouping (SCG) overview, 3                             Breast and Cervical Cancer Treatment Program
   types of SAR forms, 2–3                                               (BCCTP), 6
   where to submit SARs, 2                                             Cancer Detection Programs: Every Woman Counts
California Children's Services (CCS) Program Service                     (CDP: EWC), 1
 Code Groupings, P2: AUD CAH DIA DME                                   CDP: EWC and Medi-Cal Work Together, 2
 GM HOM IP LEA MTR OAP OB PH PSY                                       Cancer Detection Section (CDS), 1
 REH THP VC cal child ser                                              case management: CPT-4 code 99358 restrictions, 14
   chronic dialysis clinic service code group 09, 22                   case management: payment policy, 15
   cochlear implant centers service code group 05, 17                  CDP: EWC additional testing to confirm diagnosis, 7
   communication disorder centers service                              claim completion, 41
     code group 04, 16                                                 DETEC breast/cervical cancer screening cycle forms, 14
   high risk infant follow-up service code group 06, 17                diagnoses obtained outside CDP: EWC, 6–7
   medical therapy service code group 11, 24                           diagnoses obtained through CDP: EWC, 6
   ophthalmology service code group 10, 23                             LA County Waiver Program, RHC and FQHC
   orthopedic surgeon service code group 07, 18–21                       guidelines, 5
   physician service code group 01, 1–13                               notice of privacy practices, 12
   podiatry service code group 12, 24–27                               NPI billing requerments, 4
   RHC/FQHC service code group 08, 22
   special care centers service code group 02, 14–15
   transplant centers service code group 03, 16
Exclude Service Code Groups
   physician service code groups 51, 28




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
10 Section Titles/Headings Index
Cancer Detection Programs: Every Woman Counts,                      Cancer Detection Programs: Every Woman
     P2: CAH GM OB can detect (continued)                           Counts – Regional Cancer Detection Partnership
   online recipient information form, 13                            Contacts Directory, P2: CAH GM OB can detect reg, 1–2
   patient consent form, 12                                         Cardiology, P2: CAH GM cardio
   payer of last resort, 11                                            cardiography procedures: reimbursement guidelines, 1–3
   payments from recipient disallowed, 5                               cardiovascular device monitoring-implantable and
   payment rate, 40                                                      wearable device, 6–9
   program inquiries, 42                                               cardiovascular stress testing/holter monitoring, 6
   provider data-reporting requirements, 7                             echocardiographic procedures, 3–4
   provider participation requirements, 3–4                            echocardiography contrast agents, 5
   recipient eligibility criteria, 8-10                                electrocardiography (ECG) with telephone link, 5
   recipient eligibility forms, 13                                     ergonovine provocation test, 8
   recipient ID number, 14                                             genetic testing, 12
   referral providers, 4–5                                             intracardiac electrophysiological procedures, 9
   referral to BCCTP, 6                                                percutaneous transluminal coronary balloon
   regional contractors, 2                                                angioplasty, 13
   types of forms and worksheets, 11                                   percurtaneous transluminal pulmonary artery balloon
   viewing breast and cervical cancer screening cycles                 angioplasty, 15
     online, 14                                                        selected coronary intervention procedures, 13
   viewing recipient records online after recipient                    transesophageal echocardiography (TEE) codes, 10
     recertification, 15                                               wearable cardiac defibrillator (WCD) HCPCS
   where to submit claims, 42                                           code K0606, 10
Cancer Detection Programs: Every Woman Counts                       Cardiology Billing Examples: CMS-1500, P2: CAH GM
 Billing Examples – CMS-1500,                                        cardio bil cms
     P2: CAH GM OB can detect exc                                      billing tips, 1
   billing for case management following provision of                  transesophageal echocardiography professional and
      breast or cervical canser screening services, 2                    technical components rendered by same provider, 2–3
   billing tips, 1                                                     transesophageal echocardiography professional
   breast and cervical cancer screening billed with                      component only, 4-5
     annual case management, 2–3
Cancer Detection Programs: Every Woman Counts
 Billing Examples – UB-04,
     P2: CAH GM OB can detect exub
   billing tips, 1
   clinic billing for routine mammogram, 2–3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 11
Cardiology Billing Examples: UB-04, P2: CAH GM                        Chemotherapy: Drugs E-O Policy, P2: CAH GM
 cardio bil ub                                                         chemo drug e-o
   billing tips, 1                                                       eculizumab (Soliris®), 1
   transesophageal echocardiography professional and                     epirubicin (Ellence), 1–2
     technical component rendered by same provider, 2–3                  eriulin mesylate (Halaven), 2–3
   transesophageal echocardiography professional                         fludarabine, 3
     component only, 4-5                                                 fulvestrant (Faslodex), 4
Checkwrite Schedule, P1: check 1                                         gemcitabine, 5
Chemotherapy: An Overview, P2: CAH GM                                    ibritumomab tiuxetan (Zevalin), 6
 chemo an over                                                           ifosfamide, 6
   cancer clinical trials guidelines, 3–5                                interferon Alfa-2a and Alfa-2b, 7
   hormone injection therapy for malignant neoplasms, 3                  irinotecan (Camptosar®), 7
   injection codes, 1                                                    ixabepilone (Ixempra®), 8
   intravenous infusion, 1–3                                             leucovorin calcium, 8
   TAR requirement, 1                                                    leuprolide (Lupron Depot®), 9
Chemotherapy: Drugs A-D Policy, P2: CAH GM                               leuprolide acetate implant (Viadur®), 9
 chemo drug a-d                                                          medroxyprogesterone (Depo-Provera®), 10
   aldesleukin (Proleukin), 1                                            methotrexate, 10
   amifostine, 2                                                         mitomycin, 11
   azacitidine, 3                                                        mitoxantrone (Novantrone) injections, 11
   bendamustine HCI, 3                                                   nelarabine, 12
   bevacizumab (Avastin), 4–5                                            oxaliplatin (Eloxatin), 12
                          ®
   bortezomib (Velcade ), 6
   carboplatin, 7
   cetuximab, 8
    cisplatin, 9–10
    clofarabine (Cholar), 10
    cyclophosphamide, 10
    daunorubicin, 11
    decitabine, 12
    degarelix (Firmagon), 12
    denileukin diftitox, 13
    docetaxel (Taxotere), 13–14
   doxorubicin HCl liposome, 15–16




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
12 Section Titles/Headings Index
Chemotherapy: Drugs P-Z Policy, P2: CAH GM                          Chiropractic Services, P2: CHR chiro
 chemo drug p-z                                                        authorization, 2
                                               ®
   paclitaxel protein-bound particles (Abrexane ), 1                   claim information, 2
   paclitaxel (Taxol), 1–3                                             eligibility requirements, 1–2
                             ®
   panitumumab (Vectibix ), 4                                          prescription requirements, 2
   pegaspargase (Oncaspar), 4                                          program coverage, 1
   pemetrexed (Alimta), 5                                           Chiropractic Services: Billing Codes and Reimbursement
   pralatrexate (Folotyn), 6                                         Rates, P2: CHR chiro cd
   rituximab (Rituxan), 7                                              codes and rates, 1
   romiplostim (Nplate), 7                                          Chiropractic Services Billing Example: CMS-1500,
   sipuleucel-T (Provenge), 8                                        P2: CHR chiro exc
   temozolomide (Temodar), 10                                          billing tips, 1
   temsirolimus, 10                                                    chiropractic visit, 2–3
   thyrotopin alfa (Thyrogen), 11                                   CIF Completion, P2: cif co
   topotecan, 11–12                                                    CIF attachments, 6
   tositumomab, 12                                                     CIF completion reminders, 7
   trastuzumab (Herceptin), 13                                         claim form attachments, 6
   triptorelin (Trelstar), 14                                          completion instructions for all inquiries, 3
   vincristine sulfate, 14                                             denied, underpaid/overpaid and void inquiries, 3–5
   vinorelbine tartrate(Navelbine), 15                                 exceptions to using CIFs, 1–2
Child Health and Disability Prevention (CHDP)                          explanation of form items 8–10
 Program, P2: AUD CAH EAP LTC MS                                       Share of Cost, inpatient, compounds, crossovers and
 OAP PH PSY VC child                                                   tracers: separate CIFs required, 5
   billing policy for CHDP/non-CHDP providers, 1–2                  CIF Overview, P1: cif
   CHDP-covered laboratory tests, 5                                    adjustments, 1
   CHDP provider health assessment billing                             Claims Inquiry Response Letter, 2
   procedures, 3–4                                                     FI acknowledgement and CIF processing, 2
   electronic billing, 5                                               filing an appeal, 2
                                                                       reconsideration of denied claims, 1
                                                                       suspended claims, 2
                                                                       timeliness, 1
                                                                       tracers, 1
                                                                      where to submit CIFs, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 13
CIF Special Billing Instructions, P2: AH MS PH cif sp               CIF Special Billing Instructions for Outpatient Services,
   Medicare/Medi-Cal Crossover Claims                                P2: OP cif sp op
       adjustments related to Medicare adjustments, 7–8                Medicare/Medi-Cal Crossover Claims
       adjustments to Medi-Cal crossover payments, 5–6                     adjustments related to Medicare adjustments, 7–8
       billing tips for crossover CIFs, 9–10                               adjustments to Medi-Cal crossover payments, 5–6
       reconsideration of denied crossover claims, 3–4                     billing tips for crossover CIFs, 9–11
       submitting crossover CIFs, 3                                        reconsideration of denied crossover claims, 3–4
       tracing crossover claims, 8                                         submitting crossover CIFs, 3
CIF Special Billing Instructions for Inpatient Services,                   tracing crossover claims, 8
 P2: IP cif sp ip                                                      Share of Cost (SOC) Claims
   Share of Cost (SOC) Claims                                       submitting SOC CIFs, 1–2
       submitting SOC CIFs, 1–2                                     CIF Special Billing Instructions for Vision Care,
   Medicare/Medi-Cal Crossover Claims                                P2: VC cif sp vc
       adjustments related to Medicare adjustments, 7–8                Medicare/Medi-Cal Crossover Claims
       adjustments to medi-cal crossover payments, 5–6                     adjustments related to medicare adjustments, 6–7
       billing tips for crossover CIFs, 9–12                               adjustments to Medi-Cal crossover payments, 5
       reconsideration of denied crossover claims, 3–4                     billing tips for crossover CIFs, 8–9
       submitting crossover CIFs, 3                                        reconsideration of denied crossover claims, 3–4
       tracing crossover claims, 8                                         submitting crossover CIFs, 3
   Share of Cost (SOC) Claims                                              tracing crossover claims, 7
       submitting SOC CIFs, 1–2                                     CIF Submission and Timeliness Instructions,
                                                                     P2: cif sub
CIF Special Billing Instructions for Long Term Care,                   Share of Cost (SOC) Claims
 P2: LTC cif sp ltc                                                        submitting SOC CIFs, 1–2
   Medicare/Medi-Cal Crossover Claims                                  Additional Inquiries
      adjustments related to Medicare adjustments, 6–7                     submitting subsequent CIFs/appeals, 3
      adjustments to Medi-Cal crossover payments, 4–5                  CIF Submission
      billing tips for crossover CIFs, 8–10                                documenting timely submission, 3
      reconsideration of denied crossover claims, 3–4                      original CIFs, 3
      submitting crossover CIFs, 3                                         where to submit CIFs, 3
      tracing crossover claims, 7
   Share of Cost (SOC) Claims
      submitting SOC CIFs, 1–2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
14 Section Titles/Headings Index
CIF Submission and Timeliness Instructions,                         CMC, P1: cmc
 P2: cif sub (continued)                                               Claims Networks and Clearinghouses
   Claims Inquiry Acknowledgement                                          developer or vendor supplied billing software, 2
       status inquiries, 5                                                 provider or billing service developed billing
       status numbers and messages, 4–5                                      software, 3
   FI Acknowledgement of CIF                                           Claim Submission
       Claims Inquiry Acknowledgement, 2                                   attachments (supporting documentation)
       Claims Inquiry Response Letter, 2                                     for 837 v4010A1 claims, 3
   Introduction                                                            claim formatting, 3
       adjustments, 1                                                      claims adjudication and payment, 4
       reconsideration of denied claims, 1                                 CMC billing and technical manual, 3
       tracers, 2                                                          CMC help desk, 4
Claim Payment Flowchart, P1: claim pay 1–2                                 telecommunications or internet submissions, 3
Claim Submission and Timeliness Overview,                              Enrollment
 P1: claim sub                                                             CMC application/agreement form, 1
   Introduction                                                        Testing
       claim forms used to bill Medi-Cal, 1–2                               system testing, 1
   Preparing Claims                                                 CMC Developers, Vendors and Billing Service Directory,
       billing services and provider responsibility, 8               P1: cmc dir
       courier services, 8                                             * access on the Internet at www.medi-cal.ca.gov
       paper claims and submission, 8                               CMC Enrollment Procedures, P1: cmc enroll
       postage and surcharges, 8                                       application/agreement forms, 2
       submission standards, 8                                         audits, 3
       telecommunication claims, 10                                    billing services, 3
       walk-up claim delivery, 9                                       CHDP CMC requirements, 1
   Processing Claims                                                   CMC submitter number, 13
       claim denial, 7                                                 completion instructions for application/agreement forms,
       claims adjudication, 6                                           5–7
       claims in suspense, 6                                           electronic formats, 3
       CMS-1500 POS claims, 3                                          Medi-Cal and CHDP application/agreement form
       Computer Media Claims, 2                                         requirements, 4
       paper claim preparation, 3–5                                    provider participation requirements, 1
       paper claims, 3                                                 reporting submitter status changes, 13–15
       payment, 7                                                      submitting claims from physician groups, 4
       Pharmacy POS claims, 3                                          submitting claims on multiple media, 4
       Point of Service network claims, 2                              where to submit application/agreement forms, 13
       Real-Time Internet Pharmacy claims (RTIP), 2
   Resubmission Turnaround Documents, 7
   Timelines for Claims
       billing limit exception codes, 11
       delay reason codes, 11
       reimbursement reduced for late claims, 12
       six-month billing limit, 10




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 15
CMS-1500 Completion, P2: AH MS PH cms comp                          Compound Pharmacy Claim Form (30-4) Completion,
   blood, 1                                                          P2: PH compound comp
   durable medical equipment, 1                                       explanation of form items, 3–14
   explanation of form items, 3–25                                  Compound Pharmacy Claim Form (30-4) Examples,
   Medicare/Medi-Cal billing for medical supplies, 1                 P2: PH compound ex
CMS-1500 Completion for Vision Care,                                  billing tips, 1
 P2: VC cms comp vc                                                   compounded drug attachment, 6
   explanation of form items, 3–15                                    compounded prescription, 2–3
CMS-1500 Special Billing Instructions,                                compounded prescription with more than
 P2: AH MS PH cms spec                                                  25 ingredients, 4–5
   billing TAR and non-TAR procedures, 7                            Contact Lenses, P2: VC contact lens
   "by report" attachments, 1–2                                        authorization required, 1
   "from-through" billing, 2                                           bandage contact lenses, 6
   identical services billed for the same date of service, 8           contact lens examination, 3
   line-item billing, 4                                                contact lens care, 6
   submitting claims for TAR-approved services, 2                      contact lens types, 4
   submitting copies of TARs, 6                                        contact lens, other type, 6
   TARs and Medi-Services, 7                                           eyeglasses worn concurrently with contact lenses, 6
CMS-1500 Special Billing Instructions for Vision Care,                 medically necessary conditions, 1
 P2: VC cms spec vc                                                    program coverage, 1
   "by report" attachments, 1                                       Contact Lenses: Billing Examples: CMS-1500,
   claim attachment and required documentation, 1                    P2: VC contact lens ex
   identical services billed for the same date of service, 3           billing tips, 1
   submitting claims for TAR-authorized services, 2                    contact lenses, 2–3
   submitting copies of TARs, 3                                     Contracted and Non-Contracted Inpatient Services,
CMS-1500 Submission and Timeliness Instructions,                     P2: CAH IP cont ip
 P2: AH MS PH cms sub                                                  Admissions
   claims over one year old, 3–6                                           admission to contracting facilities, 15
   late billing instructions, 2                                            day of discharge or death: emergency or elective
   six-month billing limit, 1                                              admission, 15
   where to submit claims, 1                                               discharge/death: on day of admission, 15
CMS–1500 Tips for Billing, P2: AH MS PH cms tips                           emergency neonatal intensive care services, 15
   attachment reminders, 2                                             Introduction
   common billing errors, 1–2                                              Health Facility Planning areas (HFPAs), 1
   field completion reminders, 3                                       OB Admissions
   paper claim form requirements, 4                                         authorization requirements, 8–9
                                                                           day of discharge or death: OB admision, 12
                                                                           ICD-9-CM procedure and admit type code
                                                                             requirements, 11




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
16 Section Titles/Headings Index
Contracted and Non–Contracted Inpatient Services,                   Contracted Inpatient Services for Allied Health,
 P2: CAH IP cont ip (continued)                                      P2: MTR cont ah (continued)
   OB Admissions (continued)                                           Transportation Guidelines: Manual of Criteria for
       low birth-weight newborns may qualify for SSI and                Medi-Cal Authorization
         SSI-linked Medi-Cal, 14                                           emergency obstetrical delivery services, 11
       non-contract hospitals in closed areas: TAR                         introduction, 7
         requirements, 12–14                                               stable for transport guidelines, 7–11
       second pregnancy or multiple deliveries within six           Contracted Inpatient Services for Medical Services,
         months, 11                                                  P2: MS cont ms
   Open Staff Privileges                                               Admissions
       Welfare and Institutions Code, 17                                   admissions prior to contract effective date, 8
  Recipient Death                                                          admission to contracting facilities, 8
       no reimbursement after declaration of death, 16                 Introduction
       organ preservation,16                                               Health Facility Planning Areas, 1
   Selective Hospital Contracting Information                          OB admissions
       billing usual and customary charges, 6                              admit type codes, 5
       contract services, 5                                                authorization requirements, 4–5
       non-contract services, 5                                            day of discharge or death, 5
       per diem contract hospital billing, 6                               low birth-weight newborns may qualify for SSI and
       per discharge hospitals, 6–7                                         SSI-linked Medi-Cal, 7
       physician/outpatient services, 2                                    non-contract hospitals in closed areas:
       TARs: facility numbers required, 3                                   TAR requirements, 6–7
       transfers from non-contracting hospitals, 3–4                       second pregnancy or multiple deliveries within six
   Selective Hospital Contracting Reminders                                 months, 5
      reminders, 1                                                     Open Staff Privileges
Contracted Inpatient Services for Allied Health,                           Welfare and Institutions Code, 9
 P2: MTR cont ah                                                       Selective Hospital Contracting Information
   Introduction                                                            physician/outpatient services, 2
       Health Facility Planning areas (HFPAs), 1                           TARs: facility numbers required, 2–3
   Selective Hospital Contracting Information                          Selective Hospital Contracting Reminders
       covered services for non-contract hospitals, 3                      reminders, 10
       general introduction, 2
   Selective Hospital Contracting Information for Medical
    Transportation
       admission to non-contracting hospitals not approved
         for non-emergency services, 6
       admission to non-contracting hospitals when travel
         time exceeds community standards, 5
       billing for delegated services, 5
         general introduction, 4
       reimbursement for transportation to another acute
         facility, 4




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 17
Contracted Inpatient Services: Selective Hospitals                  Denti-Cal Program for Inpatient and Outpatient
 Directory, P2: IP MS OP contra 1–15                                 Services, P2: CAH EAP IP denti io
County Medical Services Program (CMSP),                                Claim Submission
 P1: county med                                                            Denti-Cal claims, 1
   access to care, 3                                                       Medi-Cal claims, 1
   aid code 50: limited services, 3                                        where to submit claims and TARs, 1
   aid code 53 recipients: proof of eligibility, 3                     Inpatient Dental Services
   companion aid code 8F, 2                                                Medi-Cal authorization, 2
   contract counties, 1                                                Outpatient Dental Services
   eligibility, 2                                                          Denti-Cal authorization, 2
Correct Coding Initiative: National, P2:                            Dialysis: Chronic Dialysis Services, P2: CAH DIA dial chr
 ADU AID AUD CAH DIA DME EAP HER MS                                    Home Dialysis
   MSS OAP PSY REH THP VC correct 1                                        composite rates, 5–6
   authorization and documentation, 2                                      dialysis training, 4
   claim denial and appeal, 5                                              HCPCS codes, 4–5
   claims processing, 5                                                Injections and Supplies
   CMS tools for providers, 2                                              blood products, 12
   national correct coding initiative, 1                                   cathflo activase: catheter declotting, 11
   NCCI column 1/column 2, 3                                               chronic outpatient hemodialysis, 11
   NCCI information: websites, 1                                           composite rates: supplies and drugs, 11–12
   modifers, 4                                                             dialysis HCPCS codes rates, 13
   services affected, 2                                                    drugs separately billed, 12
Correct Coding Initiative: National – Claim Preparation,                   epoetin alfa (Recombinant Erythropoietin), 12
 P2: ADU AID AUD CAH DIA DME EAP HER MS                                    injections, 12
   MSS OAP PSY REH THP VC correct cod 1                                    supplies, 11
   modifier approved list, 1                                               urokinase for catheter: Medi-Cal clearance, 12
   modifier placement, 1                                               Laboratory Tests
   modifier placement: CMS-1500 claim, 2                                   from-through billing, 10
   modifier placement: UB-04 claim, 3                                      routine test exceeded, 9
                                                                           routine tests, 9
D                                                                          separately billable tests, 10
Dental, P2: CAH LEA MS dental                                          Maintenance Dialysis
   fluoride varnish, 1                                                     HCPCS codes, 1–3
Denti-Cal Program, P2: CAH EAP GM IP denti                             Other Policies
   Denti-Cal provider manual/bulletins, 1                                  CMS approved dialysis exception codes, 7–8
   Denti-Cal provider/recipient telephone numbers, 1                         miscellaneous codes, 7
   Denti-Cal recipient eligibility, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
18 Section Titles/Headings Index
Dialysis: End Stage Renal Disease Services,                         Drugs: Contract Drugs List Part 3 – Over-the-Counter
 P2: CAH DIA GM dial end                                             Cold/Cough Preparations, P2: PH drugs cdl p3,
   authorization, 2                                                    over-the-counter (OTC) cold/cough preparation
   end stage renal disease pilot project, 6                             ingredient specifications, 1–4
   home dialysis, 1                                                 Drugs: Contract Drugs List Part 4 – Therapeutic
   inpatient physician services, 6                                   Classifications, P2: PH drugs cdl p4, 1–19
   outpatient physician services, 3–5                               Drugs: Contract Drugs List Part 5 – Authorized Drug
   authorization, 2                                                  Manufacturer Labeler Codes, P2: PH drugs cdl p5, 1–17
   treatment modalities, 1                                          Drugs: Contract Drugs List Part 6 – Deleted Drugs,
Dialysis Example: CMS-1500, P2: GM dial ex cms                       P2: PH drugs cdl p6
   billing tips, 1                                                     continuing care exceptions, 1-19
   hemodialysis, 2–3                                                Drugs: Contract Drugs List Part 7– Preferred
Dialysis Examples: UB-04, P2: CAH DIA dial ex ub                    TAR-Approved Drug List, P2: PH drugs cdl p7, 1
   billing for blood used at a dialysis clinic, 4–5                 Drugs: Contract Drugs List Part 8 – Step Therapy,
   billing tips, 1                                                   P2: GM PH drugs cdl p8, 1–2
   monthly dialysis fee ("from-through" format), 2–3                Drugs: Contract Drug List Part 9– FUL List, P2: GM
Distinct-Part Long Term Care Facilities,                             PH drugs cdl p9. 1–39
 P2: CAH LTC distinct                                               Drugs: Contract Drug List Part 10– MAIC List, P2: GM
   distinct-part hospital LTC billing for lab and X-ray              PH drugs cdl p10. 1–9
     services, 1                                                    Drugs: MAIC Rate Review– P2: GM PH
Drugs: Contract Drugs List Introduction,                             drugs maic rate , 1
 P2: PH drugs cdl intr                                              Drugs: MAIC Rate Review Application– GM PH, 1–2
   compounded prescriptions, 2                                      Drug Use Review (DUR) Program, P2: CAH MS PH drug
   legend drugs, 2                                                     Drug Use Review board, 11
   non-legend over-the-counter (OTC) drugs, 2                          DUR board responsibilities, 12–14
   over-the-counter antihistamine, expectorant, nasal                  general requirements, 1
     decongestant, cough preparations and combinations, 2              Medi-Ca667l offers on-line prospective DUR, 3–4
   public health service covered entities, 2                           on-line real-time DUR processing, 4–7
Drugs: Contract Drugs List Part 1 – Prescription Drugs                 patient counseling requirements, 8–9
 (A through D), P2: PH drugs cdl p1a, 1–46                             patient record keeping (medication records), 9–10
Drugs: Contract Drugs List Part 1 – Prescription Drugs                 pharmacy responsibilities and software options, 3
 (E through M), P2: PH drugs cdl p1b, 1-57                             prospective DUR screen requirements, 1–2
Drugs: Contract Drugs List Part 1 – Prescription Drugs
 (N through R), P2: PH drugs cdl p1c, 1-39
Drugs: Contract Drugs List Part 1 – Prescription Drugs
 (S through Z), P2: PH drugs cdl p1d, 1-25
Drugs: Contract Drugs List Part 2 – Over-the-Counter
 Drugs, P2: PH drugs cdl p2, 1-13




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 19
Durable Medical Equipment (DME): An Overview,                       Durable Medical Equipment (DME): Bill for DME,
 P2: DME PH dura                                                     P2: DME PH dura bil dme
   Billing Information                                                Ambulation Devices
       accesories or supplies reimbursable only for patient-              Gait trainer, 7-8
         owned equipment, 12                                          Bathroom Equipment
       accessories or supplies separately reimbursable for                commode chairs 8
         associated equipment, 12                                         coverage, 8
       "by report" requirements, 9                                     Coverage Criteria for Hospital Beds
       repair or maintenance of equipment, 10–11                         certification of medical necessity, 12
       sales tax, 10                                                  General Information
       stand alone items, 12                                              DME group, 1
   General Information                                                Hospital Beds and Accessories
       eligibility requirements, 4                                        adult hospital bed and accessories, 10
       non-physician medical practioners: furnishing or                   billing restriction, 9
        ordering drugs or devices, 5                                      criteria for pediatric beds, 9
       prescription requirements, 4–5                                     pediatric crib, 9
       program coverage, 1–4                                              types of hospital beds, 11
   Medicare/Medi-Cal Crossovers                                       Miscellaneous equipment, Accessories and Supplies
       reimbursement, 14–15                                               blood glucose monitors, 17
   Reimbursement                                                          blood pressure equipment, 18
       net purchase price, 13                                             breast-feeding: lactation management aids, 19–21
       purchase frequency limits, 13                                      "by report" reimbursement, 31
       upper billing limit, 13                                            electrodes and lead wires: HCPCS codes A4556
   Treatment Authorization Request (TAR) Information                        & A4557, 30
       certificate of medical necessity, 6–9
       authorization, 5–6




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
20 Section Titles/Headings Index
Durable Medical Equipment (DME): Bill for DME,                      Durable Medical Equipment (DME): Bill for Infusion
 P2: DME PH dura bil dme (continued)                                 Equipment, P2: DME PH dura bil inf
      Haberman feeder: HCPCS Code S8265, 21                            ambulatory infusion pumps, 2
      helmet interface replacement HCPCS code                          authorization, 1
         A8004, 21                                                     billing requirements, 5
      helmets-prefabricated, 21                                        enteral nutrition infusion pumps, 2
      low-intensity ultrasound device, 29                              implantable infusion pumps, 4
      miscellaneous DME supplies: HCPCS code                           implantable infusion pump replacements, 4
         A9900, 31                                                     infusion equipment group, 1
      Negative Pressure Wound Therapy (NPWT)                           infusion pumps, 2
         Devices, 21–23                                                insulin infusion pumps, 3–4
      non-invasive osteogenesis, 24                                    mechanical external infusion pumps, 4
      positioning seat, 28                                             miscellaneous DME supplies: HCPCS code A9900, 6
      Pulsed Irrigation Enhanced Evacuation                            parenteral infusion, 4
         (PIEE), 25–26                                                 pump supplies, 4
      ramps, portable, 27-28                                           where to submit TARs, 1
      spinal electrical device, 28                                  Durable Medical Equipment (DME): Bill for Oxygen
      Transcutaneous Electrical Nerve Stimulators (TENS):            and Respiratory Equipment, P2: DME PH dura bil oxy
         HCPCS code A4595, 30                                          oxygen contents, oxygen equipment and respiratory
      wearable cardiac defibrillator (WCD) HCPCS code                   equipment group, 1–5
         K0606, 29                                                     authorization required, 5
   Non-Wheelchair DME                                                  Aerosol Mask, 21
      gait trainer devices, 7                                          Apnea Monitors and Supplies, 35–36
      non-wheelchair rentals subsequently rented to                    Bi-Level Positive Airway Pressure (Bi-PAP)
         recipients, 7                                                  Equipment, 25
      pricing discounts, 7                                             Bi-Level Positive Airway Pressure ST (Bi-PAP ST)
      reimbursement                                                     Equipment, 26
        "by report" codes, 4–5                                         Continuous Positive Airway Pressure (CPAP)
         listed codes, 4                                                Equipment, 22–24
   Patient Lifts and Standing Frames                                   Humidifiers, 32–33
       standing systems and standing frames, 13–15                     Miscellaneous Supplies, Accessories and
   Patient Transfer Systems                                             Service Components, 43
      multi-positional patient transfer systems, 15                    Nebulizers and Compressors, 19–20
      stairway chairlifts, 15                                          Oscillatory Devices for Airway Clearance
   Pneumatic Compressors                                                   hand-held positive expiratory pressure devices, 38
      lymphedema pumps/pneumatic compression                               high frequency chest wall oscillation devices, 40
          devices, 15                                                      intrapulmonary percussive ventilators/devices, 39
  Treatment Authorization Requests                                     Oxygen Conserving Devices, 16–17
      documentation, 3                                                 Oxygen Contents and Oxygen Equipment, 6–12
      where to submit TARs, 3                                              oxygen flow rate modifiers, 13
   Unlisted Equipment                                                      billing guidelines chart, 14–15
      billing requirements, 31




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 21
Durable Medical Equipment (DME): Bill for Oxygen                    Durable Medical Equipment (DME): Bill for
 and Respiratory Equipment, P2: DME PH dura bil oxy                  Wheelchairs and Wheelchair Accessories, P2:
   (continued)                                                       DME PH dura bil wheel
   Oxygen Stand/Rack, 18                                              certificate of medical necessity, 2
   Percussors for Chest Physiotherapy, 37                             claim denials, 10
   Regulators, 17                                                     documentation, 2
   Suction Machines, 34                                               lightweight wheelchairs, 3
   Unlisted Oxygen Equipment and Respiratory                          pediatric, 7
     Equipment, 41–42                                                 power wheelchair, 4
   Ventilators (Back-Up), 30–31                                       power wheelchair accessories, 6
   Ventilators (Primary), 27–29                                       power wheelchair interface, 4–5
Durable Medical Equipment (DME): Bill for                             pricing discounts, 10
  Therapeutic Anti-Decubitus Mattresses and                           prior authorization, 3
  Bed Products, P2: DME PH dura bil thp                               reimbursement for wheelchair "by report" codes, 8–9
   alternating pressure pads, 1                                       reimbursement listed codes, 7
   authorization, 11–14                                               repair and maintenance, 10
   definition, 2–5                                                    scooters, 10
   flowchart A. Anti-Decubitus Care (ADC)–group II                    "sports" model wheelchair, 3
     products–initial request, 15                                     stair-climbing wheelchair, 6
   flowchart B. Anti-Decubitus Care (ADC)–group II                    Treatment Authorization Requests, 1
     products–reauthorization request, 16                             ultralightweight wheelchairs, 3
   flowchart C. Anti-Decubitus Care (ADC)–group II                    wheel bearings, 4
     products–authorization requests for recipients with              wheelchair accessories not separately
      chronic wounds, 17                                                reimbursable, 11–12
   flowchart D. Anti-Decubitus Care (ADC)–group I or                  wheelchair group, 1
      preventive products, 18
   “from through” billing, 2
   group I pressure sore products, 6–9
   group II pressure sore products, 6–9
   group III pressure sore products, 6–9
   guidelines for selecting specialty beds and surfaces, 5
   introduction, 1
   medical necessity, 9–11
   medicare/medi-cal crossover claims, 2
   product prices, 1
   repair of equipment, 2
   replacement pad for alternating pressure pad:
     HCPCS code A4640, 1
   therapeutic anti-decubitus mattresses and bed products, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
22 Section Titles/Headings Index
Durable Medical Equipment (DME): Billing Codes and                  Electronic Methods for Eligibility Transactions and
 Reimbursement Rates, P2: DME OAP PH THP dura cd                     Claim Submissions, P1: elect
   authorization, 1                                                    personal computer/internet, 1
   codes and rates, 2–31                                               Point of Service devices, 2
   rentals and purchases, 1                                            telephone, 1
Durable Medical Equipment (DME): Billing Codes for                  Eligibility: Recipient Identification, P1: elig rec
California Children's Services (CCS), P2: DME OAP                      Medi-Services, 4
  PH THP dura cd ccs                                                   month-to-month eligibility, 1
   CCS exclusive, 1                                                    point of service network, 2
Durable Medical Equipment (DME) Billing Codes:                         recipient identification: provider obligations, 1
 Frequency Limits, P2: DME OAP PH THP                                  retroactive eligibility, 3
 dura cd pre 1–4                                                    Eligibility: Recipient Identification Cards, P1: elig rec crd
Durable Medical Equipment (DME): Billing Examples,                     altered ID cards, 2
 P2: DME PH dura ex                                                    Benefits Identification Card, 1
   billing tips, 1                                                     newborn infant using mother's ID, 4
   "by report" DME billing requiring catalog page                      paper ID cards for immediate need and minor consent
     attachment, 18–24                                                   program recipients, 2
   "from-through" billing for rental of an antidecubitus               presumptive eligibility program recipients, 3
     support bed, 16–17                                                second ID helps confirm recipient's identification, 1
   gas oxygen system rental with modified oxygen                    Eligibility: Service Restrictions, P1: elig rstrict
     flow, 12–13                                                       Medicare coverage, 3
   liquid oxygen system rentals, 10–11                                 Other Health Coverage coding, 3
   listed DME, 2–4                                                     service restriction messages and codes, 1
   oxygen concentrator with modified oxygen flow                       Share of Cost, 3
     and portable gas oxygen system rental, 14–15
   purchase of an infant apnea monitor, 8–9
   rental of an infant apnea monitor, 6–7
   wheelchair batteries, replacement parts and labor, 4–5

E
Electronic Fund Transfer, P1: eft
   applying for EFT, 1
   change in bank accounts, 2
   EFT cancellation, 2
   EFT payments, 2
   eligible providers, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 23
Eligibility: Special Groups, P1: elig special                       Evaluation & Management (E&M), P2: CAH MS eval
   dialysis special treatment program, 3                               new patient reimbursement, 1
   emergency assistance program: aid codes 4K and 5K, 3                nursing facilities: frequency of physician visits, 9
   institutional inmate status, 1                                      outpatient visits: reimbursement based on recipient's
   managed care information, 3                                          age, 10
   special program information, 3                                      pediatric critical care patient transport codes 99466
   Total Parenteral Nutrition special treatment program, 3              and 99467, 13
Enteral Nutrition: List of Available Products,                         pharmacologic management: not separately reimbursable
 P2: DME PH enteral 1–13                                                with code 90862, 10
    reimbursement guidelines, 2                                        physician office/outpatient consultations, 12
    list of other available standard enteral                           physician standby/detention time, 13
      nutrition products, 13                                           physician visits: "state" hospitals, 12
Evaluation & Management (E&M), P2: CAH MS eval                         post-operative services not separately reimbursable when
   additional E&M home visits require justification, 11                 billed within surgery follow-up period, 11
   board and care facility services and home visit codes, 8            pre-operative exam billing by outpatient surgery
   cutback reimbursement rates, 9–10                                    clinics, 11
   E&M place of service codes, 3–4                                     pre-operative exam not separately reimbursable from
   E&M services not separately reimbursable, 4                          surgery, 11
   E&M services separately reimbursable, 2–3                           preventive medicine services for children, 14
   emergency department services, 6                                    prolonged E&M services, 4
   emergency room visits and critical care not separately              routine or standing orders–hospitals and nursing
     reimbursable, 12                                                   facilities level B (NF-B), 8
   established patient reimbursement, 2
   general information, 1
   hospital visit/discharge services rendered on
     same date of service, 10
   hospital visits, 9
   initial inpatient consultations, 12
   neonatal and pediatric intensive care guidelines, 15–18
   newborn care, 14




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
24 Section Titles/Headings Index
Expanded Access to Primary Care (EAPC) Program,                     Eye Appliances, P2: VC eye app
 P2: EAP expand                                                        Billing Information
   background, 1                                                           aphakia/pseudophakia: Medicare/Medi-Cal
   billing, 2                                                              crossovers, 9
   case management services, 10                                            appliances requiring prior authorization, 2
   CHDP services, 12                                                        balance lenses, 8
   clinic standards, 1                                                     dispensing fees for PIA optical laboratories, 6
   eligible recipients, 3–4                                                headbands, 9
   non-qualifying visits, 9                                                lens codes in non-PIA counties, 6
   notification: significant operation changes, 12                         miscellaneous items, 6
   outpatient visit criteria, 6–8                                          prescription requirements for dispensing providers, 4
   outpatient visits, 5                                                    procedures, 7–8
   program policies, 1                                                     undeliverable custom-made appliances, 5
   provider number, 2                                                      unlisted eye appliances, 9
   recipient identification, 5                                         General Information
   reimbursement, 11                                                       appliance requiring authorization, 2
   service requirements, 2                                                 covered eye appliances, 1
   sliding fee applicable to CHDP patients, 11                             non-covered eye appliances, 3
   state license, 2                                                        program coverage, 1
Expanded Access to Primary Care (EAPC) Program                             record keeping, 4–5
 Billing Codes, P2: EAP expand cd                                          replacement of lost, stolen, broken or
   procedure codes, 1                                                        damaged appliances, 4
                                                                           supplemental eye appliances, 3
                                                                    Eyeglass Frames, P2: VC eyeglass fram
                                                                       billing, 2
                                                                       eyeglass cases, 5
                                                                       frame repair/parts, 5
                                                                       multifocal and nearpoint prescription for recipients
                                                                          younger than 38 years of age, 5
                                                                       non-covered frames, 1
                                                                       program coverage, 1
                                                                       replacements, 2
                                                                       single vision eye glasses in lieu of bifocals, 4




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 25
Eyeglass Frames Example: CMS-1500                                   Family Planning, P2: CAH MS fam planning
 P2: VC eyeglass fram ex                                               billing, 3
   billing tips, 1                                                     contraceptives, 7–11
   frame replacement, 2–3                                              diagnosis codes, 5–6
Eyeglass Lenses, P2: VC eyeglass lens                                  family planning counseling and modifier -ZQ, 4–5
   Billing Information                                                 participation and services, 1–2
       dispensing fees for PIA optical laboratories, 4                 postpartum mini-laparotomy, 10
       lens codes in non-PIA counties, 4                            Family Planning Billing Example: CMS-1500,
       non-PIA covered lenses, 8                                     P2: CAH MS fam planning cms
       procedures, 5–8                                                 billing tips, 1
   fresnel prisms, 11                                                  other contraceptives, 2–3
   lenses reimbursable for recipients with Other Health             Family Planning Billing Example: UB-04,
    coverage, 11                                                     P2: IP fam planning ub
Eyeglass Lenses, P2: VC eyeglass lens (continued)                      billing tips, 1
   program coverage, 1–2                                               other contraceptives, 2–3
   provider lens acquisition, 9                                     Forms: Legibility and Completion Standards,
Eyeglass Lenses Examples: CMS-1500,                                  P2: forms leg
 P2: VC eyeglass lens ex                                               attachments, 4
   bifocals prescribed for recipients younger                          corrections, 3–4
     than 38 years of age, 4–5                                         date format, 3
   billing tips, 1                                                     provider signature, 3
   eyeglass replacement: previous lenses less                          submitting forms, 1–2
     than two years old, 6–7                                           typed and handwritten forms, 2–3
   single vision lenses in lieu of bifocals, 2–3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
26 Section Titles/Headings Index
Forms Reorder Request: Guidelines, P2: forms reo                    Genetically Handicapped Persons Program (GHPP),
   change of address/change of status, 2                             P2: AUD CAH DIA DME GM HOM IP LEA MTR
   ordering electronic billing forms, 2                              OAP OB PH PSY REH THP VC genetic (continued)
   ordering hardcopy billing forms, 1                                  pharmacy SAR rquirements, 8
   returned orders, 2                                                  physician SAR requirement, 6
Forms Reorder Request: Inpatient and Outpatient                        physician SAR requirements for rendering provider, 6
 Services, P2: IP OP forms reo io                                      procedure codes, 8
   explanation of form items, 2                                        program overview, 1
   request for mental health stay in hospital (18-3), 2                remittance advice details and warrants, 15
Forms Reorder Request: Long Term Care,                                 rsubmission turnaround documents, 15
 P2: LTC forms reo ltc                                                 service code groupings (SCG), 4
   explanation of form items, 2                                        types of SAR forms, 4
Forms Reorder Request: Medical Services and                            where to sumit SARs, 4
 Allied Health, P2: AH MS forms reo ma                              Genetic Counseling and Screening, P2: CAH MS
   explanation of form items, 2                                      gene coun
Forms Reorder Request: Pharmacy, P2: PH forms reo ph                   Chorionic Villus Sampling, 6
   explanation of form items, 2                                        genetic counseling and screening, 7
Forms Reorder Request: Vision Care,                                    genetic testing for pregnant Medi-Cal patients, 1
 P2: VC forms reo vc                                                   newborn metabolic screening panel, 5
   explanation of form items, 2                                        ordering literature, forms and supplies, 1
                                                                       prenatal screening: authorization/billing
G                                                                        requirements, 2–4
Genetically Handicapped Persons Program (GHPP),                     Genetic Screening Billing Examples:
 P2: AUD CAH DIA DME GM HOM IP LEA MTR                               CMS-1500, P2: CAH MS gene ex
 OAP OB PH PSY REH THP VC genetic                                      billing tips, 1
   aid codes, 7                                                        newborn screening panel (S3620), 2–3
   authorization, 3
   claims submission and timeliness requirements, 14
   claims inquiry forms, 15
   CMC billing, 14
   denti-cal, 14
   DME and medical supply SAR requirements, 9
   diagnosis codes, 11–12
   diagnostic laboratory SAR requremants, 7
   eligibility requirements, 1–2
   home health agencies SAR requirements, 10
   hospitalization and ancillary services, 12
   inpatient SAR requirements, 7
   managed care plans, private health insurance and
     commercial HMOs, 13




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 27
H                                                                   Hearing Aids: Billing Codes and Reimbursement Rates,
HCPCS Introduction, P2: AH IP MS OP VC hcpcs                         P2: AUD hear aid cd
   eye appliances, 2                                                   codes and rates, 1–2
   HCPCS, 1                                                         Hearing Aids: Billing Example, P2: AUD hear aid ex
   HCPCS billing exceptions, 2                                         billing tips, 1
   HCPCS books, 3                                                      purchase of a hearing aid, 2–3
   Medi-Cal HCPCS benefits, 3                                       Heroin Detoxification, P2: CAH GM HER heroin
   medical supplies, 2                                                 Coverage
   ophthalmological and professional services, 2                           inpatient coverage, 3
HCPCS Level III Interim Code List: Reimbursable                            outpatient coverage, 3
 Medi-Cal-Only Codes,                                                  Participation Standards
 P2: AH IP MS OP VC hcpcs iii, 1–4                                         Darvon N, 1
HCPCS Level II List: Reimbursable National Codes,                          Methadone, 1
 P2: CAH DIA MS hcpcs ii, 1–5                                              non-narcotic pain medications, 2
Health Access Programs (HAP), P1: health acces                         Participation Standards
   Family PACT, 1                                                      physician requirements, 1
   HAP card, 1                                                         physician's office services, 2
Hearing Aids, P2: AUD hear aid                                      Heroin Detoxification Billing Codes,
   authorization, 2                                                  P2: CAH HER heroin cd
   California Children's Services (CCS), 1                             heroin detoxification service codes, 1–2
   eligibility requirements, 1                                         separately billable services, 2
Hearing Aids: Billing, P2: AUD hear aid bil
   Bilateral Contralateral Routing of Signals (BICROS)
    hearing aids, 4
   binaural hearing aids, 2
   Contralateral Routing of Signals (CROS) hearing aids, 3
   date of service, 1
   EPSDT supplemental service hearing aid claims, 6
   guarantees, 8
   hearing aid supplies and accesories for specific needs, 6
   Medicare non-covered, 7
   modifiers, 1
   monaural hearing aids, 1
   programmable or ditigal hearing aid systems, 5
   reimbursement, 7–8
   repairs, 8




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
28 Section Titles/Headings Index
Home and Community-Based Services (HCBS),                           Home Health Agencies (HHA) Billing Codes and
 P2: HOM home                                                        Reimbursement Rates, P2: HOM home hlth cd
   background, 1                                                    Home Health Agencies (HHA) Billing Examples,
   contact, 9                                                        P2: HOM home hlth ex
   general waiver provisions, 4                                        billing tips, 1
   HCBS waivers, 5                                                     multiple services, same procedure on same day, 9–10
   home and community-based services, 1                                initial case evaluation billed on same day as skilled
   in-home medical care waiver, 3                                       nursing visit, 5–6
   in-home operations (IHO) section, 7                                 services to both mother and baby on same day, 7–8
   in-home operations inquiries, 7                                     skilled nursing services: "from-through" billing, 2–4
   Medi-Cal eligibility, 4                                          Hoptel Services, P2: CAH IP hoptel
   model-NF waiver, 3–4                                                billing procedures, 1
   nursing facility (NF) waiver, 3                                     reimbursement, 1
   scope of practice by provider type, 3                            Hospice Care, P2: CAH GM HOS IP hospic
   service and provider definitions, 2                                 attending physician and unrelated services, 6
   special billing instructions, 8–9                                   classification of care, 4–5
   waiver requirements, 5–6                                            eligible providers, 1
Home and Community-Based Services (HCBS) Billing                       eligible recipients, 1
 Codes and Reimbursement Rates, P2: HOM home cd                        emergency services, 7
   codes and rates, 1                                                  patient certification/recertification required, 2
   code and rate correlation table 2–8                                 patient revokes or discharges, 3
Home Health Agencies (HHA), P2: HOM home hlth                          periods of care, 2
   authorization/frequency limitations, 2                              primary care physician services, 5–6
   description field of claim form, 8                                  Residential Care Facilities for the Elderly (RCFE), 7
   filling diabetic syringes, 7                                        service restrictions, 3
   home-bound recipient: medically necessary                        Hospice Care Billing Codes, P2: HOS hospic bil cd
     services, 7–8                                                     room and board codes: revenue code 658, 1
   home health aide services, 5                                        service codes, 1
   home health psychiatric nursing services, 4                      Hospice Care Billing Examples, P2: HOS hospic bil ex
   medical supplies provided by HHA, 6                                 billing tips, 1
   program coverage, 1                                                 "from-through" billing of general inpatient
   same day services: mother and baby, 3                                hospice care, 2–3
   same day services: skilled care services, 3                         room and board billing, 4




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 29
Hospice Care: General Billing Instructions,                         Hysterectomy, P2: CAH IP MS hyst
 P2: HOS hospic ge                                                     anesthesia time, 6
   billing procedures, 1                                               exceptions for hysterectomy consent
   extension of care: OBRA 1990, 5                                       form attachment, 4–5
   home and respite care: authorization not required, 4                guidelines for hysterectomies, 5–6
   Medicare/Medi-Cal patients, 2                                       hysterectomy consent form, 1
   Other Health Coverage, 1                                            hysterectomy: consent form required, 2–4
   record retention requirements, 5-6                                  hysterectomy inquiries, 6
   Remittance Advice Details, 5                                        no waiting period, 1
   room and board billing instructions, 4                              TAR requirement, 1I
   special physician services, 1                                    Incontinence Medical An Overview, P2: DME PH incont
   Treatment Authorization Request: general inpatient care             claim information, 8
    (HCPCS code Z7106), 3                                              DME/pharmacy providers: Disclosure Form
Hospice Care: General Inpatient Information Sheet,                       requirements, 6
 P2: HOS hospic ge inf                                                 eligibility requirements, 3
   explanation of form items, 3–4                                      guaranteed prices, 10
   Hospice General Inpatient Information Sheet, 1–2                    other health coverage documentation, 4
Hospital Recoupment: Administrative Adjustment                         prescription requirements, 5
 Requests, P2: IP hosp recoup                                          program coverage, 1
   administrative adjustment requests: MIRL guidelines, 1              reimbursement, 7
   administrative adjustment requests: PIRL guidelines, 2              self-certification for other health coverage, 4
   formal hearing when a request for administrative                    treatment authorization request (TAR), 9
    adjustment is denied: MIRL, 2                                      toll-free telephone numbers for contractors, 10
   formal hearing when a request for administrative                 Incontinence Medical Supplies: Contracted/Manufacture
    adjustment is denied: PIRL, 2                                    List, P2: DME PH incont con, 1
   hospital recoupment: introduction, 1                             Incontinence Medical Supplies Example: CMS-1500, P2:
   where to submit AARs, 2                                           DME PH incont ex, 1–3
   where to submit appeals of administrative adjustment
    requests, 3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
30 Section Titles/Headings Index
Incontinence Products: Belted Undergarments, P2: DME                Incontinence Supplies Prescription Form: Completion,
 PH incont prod belt                                                 P2: CAH DME GM PH incont sup com
    belted undergarments, 1–2                                          explanation of form items, 4–6
    billing requirements, 1                                            Incontinence Supplies Prescription Form, 1–3
Incontinence Products: Briefs, Disposable, P2: DME PH               Indian Health Services (IHS), Memorandum of
 incont prod brief                                                   Agreement (MOA) 638, Clinics,
    billing requirements, 1                                          P2: ADU CAH ihs moa
    disposable briefs, 1–14                                            CHDP/EPSDT reporting requirements and billing
Incontinence Product: Cream and Washes, P2: DME PH                      for CHDP patients, 5–6
 incont prod cr                                                        enrollment, 1
    billing requirements, 1                                            medi-services, 2
    incontinence creams and washes, 1–10                               medical visits, 3
Incontinence Product: Protective Underwear,                            other types of visits, 4-5
 Disposable, P2: DME PH incont prod protect                            prescription, 2
    billing requirements, 1                                            program history, 1
    disposable protective underwear, 1–10                              services available, 2
Incontinence Products: Reusable Underwear, P2: DME                     TARs, 3
 PH incont prod reus                                                Indian Health Services (IHS), Memorandum of
    billing requirements, 1                                          Agreement (MOA) 638, Clinics: Billing Codes,
    reusable underwear, 1–12                                         P2: ADU CAH ihs moa cd
Incontinence Products: Shields, Liners and Pads,                       IHS/MOA all-inclusive per visit codes, 1–3
 Disposable, P2: DME PH incont prod shield                             IHS: services for recipients enrolled in a
    billing requirements, 1                                             Managed Care Plan, 4
    disposable shields, liners and pads, 2–11                          IHS: services not covered by recipient's
Incontinence Products: Underpads, Disposable, P2: DME                   Managed Care Plan, 4
 PH incont prod und
    billing requirements, 1
    authorization, 1
    disposable underpads, 1–8




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 31
Immunizations, P2: CAH, DIA, MS, REH immun                          Injections: Drugs A-L Policy, P2: CAH DIA MS REH
   BCG vaccine, 3                                                    inject drug a-l
   Billing guideline, 1                                                17a-hydroxyprogesterone, 1
                                                                                            ®
   DTP/DtaP immunization series, 3                                     abatacept (Orencia ), 1
   H1N1 vaccine, 4                                                     abobotulinumtoxin A (Dysport), 2–3
   hepatitis A vaccine, 4                                              acyclovir, 4
   hepatitis A and B combination vaccine, 7                            agalsidase beta (Fabrazyme), 4
                                            ™
   hepatitis B immune globulin (hepagam B )                            algucosidase alfa (Lumizyne, Myozyme), 4
                                                                                           ®          ®
     intramuscular, 7                                                  alteplase (Activase /Cathflo ), 4
                                            ™                                                  ™
   hepatitis B immune globulin (hepagam B )                            anidulafungin (Eraxis ), 4
     intravenous, 7                                                    antigens for allergy desensitization, 5
                                                                                              ®
    hepatitis B immunization schedules, 5                              aripiprazole (Abilify ), 5
                                                    ®
    human papilloma virus bivalent vaccine (Cervarix ), 8              baclofen, 5–6
                                    ®
    human papilloma virus (Gardasil ), 8                               betamethasone (Celestone Soluspan), 7
                                                                                                 ®
    measles, mumps and rubella vaccine (2nd dose only), 8              bevacizumab (Avastin ), 7
    meningitis vaccine: menactra or menveo, 9                          C1 esterase inhabitor (Cinryze), 7
    monovalent measles, mumps and rubella                              calcitriol, 7
     vaccinations, 8–9                                                 cefotaxime, 8
                           ®
    palivizumab (Synagis ), 9–10                                       ceftriaxone sodium, 8
    pentacle vaccine, 10                                               certolizumab pegol (Cimzia), 9
                                                                                          ®
    rabies biologics, 11                                               cidofovir (Vistide ), 9
    Tdap vaccine, 11                                                   collagenase clostridium histolyticum (Xiaflex), 10
                                                                                                             ®
    zoster vaccine (Zostavax), 12                                      corticorelin ovine triflutate (Acthrel ), 11
Immunization Code List, 1–2                                            corticosteroids, 11
Injection: An Overview, P2: CAH, DIA, MS, REH                          cosyntropin, 11
                                                                                               ®
  inject an over                                                       daptomycin (Cubicin ), 11
                                                                                               ®
     billing guidelines, 1–2                                           darbepoetin (Aranesp ) Codes J0881 and J0882, 12–13
Injection: Billing Example for CMS-1500, P2 CAH, DIA,                  denosumab (Prolia XGEVA), 14
   MS, REH inject bil cms, 1–4                                         dexamethasone intravitreal implant (Ozurdex), 15
                                                                                              ®
Injection: Billing Example for UB 04, P2 CAH, DIA,                     dolasetron (Anzemet ), 15
                                                                                              ™
   MS, REH inject bil ub, 1–3                                          doripenem (Doribax ), 15
                                                                                                   ®
Injection: Code List, P2 CAH, DIA, MS, REH                             doxercalciferol (Hectorol ), 15
    inject cd list, 1–19                                               enzyme replacement drugs, 16–22
                                                                       epoetin alfa, 22–26
                                                                                                        ®
                                                                       etonogestrel implant (Implanon ), 27
                                                                       ferric gluconate, sodium complex in sucrose
                                                                                   ®
                                                                         (Ferrlecit ), 27
                                                                       ferumoxytol (Feraheme), 27–28
                                                                                               ®
                                                                       filgrastim (Neupogen ), 29
                                                                                             ®
                                                                       fomepizole (Antizol ), 30
                                                                                               ®
                                                                       fosaprepitant (Emend ), 30




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
32 Section Titles/Headings Index
Injections: Drugs A-L Policy, P2: CAH DIA                           Injections: Drugs M-Z policy, P2: CAH DIA
  MS REH inject drug a-l (continued)                                  MS REH inject drug m-z
   galsulfase (Naglazyme), 30                                          medroxyprogestereone acetate, 1
                       ®
   goserelin (Zoladex ), 30 vc                                         mesna, 1
   granisetron, 31                                                     methotrexate, 2
                                                                                                ®
   growth hormone injections, 31                                       micafungin (Mycamine ), 2
                         ®
   hemin (Panhematin ), 32                                             naltrexone (Vivitrol), 3
                                                                                             ®
   histrelin acetate, 32                                               natalizumab (Tysabri ), 3
                                  ®                                                        ®
   histrelin acetate (Supprelin LA), 32                                omalizumab (Xolair ), 4
                               ®
   histrelin implant (Vantas ), 32                                     onabotulinumtoxinA (Botox), 5–7
   human fibrinogen concentrate (RiaSTAP), 32                          ondansetron HCl (Zofran), 8
                                                                                               ®
   hyaluronan (Orthovisc) high molecular weight, 33                    palifermin (Kepivance ), 9
   hylan G-F 20 (Synvisc or Synvisc-one), 33-34                        paliperidone palmitate (Invega Sustenna), 9
                          ®
   ibandronate (Boniva ), 34                                           palonosetron, 9
                                                                                            ®
   idursulfase (Eleprase), 34                                          pamidronate (Aredia ), 10
                                                                                             ®
   imiglucerase (Cerezyme), 35                                         paricalcitol (Zemplar ), 11
   immune globulin 35–36
   incobotulinumtoxinA (Xeomin), 36–37
                            ®
   infliximab (Remicade ), 38–39
   iron sucrose (Venofer), 39
   lacosamide (Vimpat), 40
                             ®
   lanreotide (Somatuline ), 41
   laronidase (Aldurazyme), 41
                                ®
   leuprolide (Lupron Depot ), 41
                            ®
   levetiracetam (Keppra ), 42
                                    ®
   levonorgestrel implant (Norplant ll), 42




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 33
Injections: Drugs M-Z policy, P2: CAH DIA                           Injections: Hydration
  MS REH inject drug m-l (continued)                                   hydration or therapeutic/prophylactic/diagnostic injection
                                 ®
   pegademase bovine (Adagen ), 11                                      CPT-4 codes 96360-96361, 96365-96370, 96375, 1
                          ®
   pegaptanib (Macugen ), 11                                           additional sequential and concurrent infusion CPT-4
                             ®
   pegfilgrastim (Neulasta ), 12                                        codes 96367-96368, 1
                        ®
   plerixafor (Mozobil ), 12                                           place of service/facility type restriction, 2
   protein C concentrate (Ceprotin), 13                             Inpatient Mental Health Services Program,
                           ™
   ranibizumab (Lucentis ), 13                                       P2: IP inp ment
   rilonacept (Arcalyst), 13                                           administrative days, 15
   rimabotulinumtoxinB (Myobloc) 14–15                                 ancillary charges, 13
                       ®
   rituximab (Rituxan ), 16                                            authorization, 2–3
                            ®
   sargramostim (Leukine ), 17                                         billing procedures, 13
                      ™
   secretin (SecreFlo ), 18                                            claim inquiries and appeals, 15
   sermorelin acetate, 19                                              crossover inpatient services: deductibles and
   sodium hyaluronate (Euflexxa), 19                                     coinsurance, 15
   sodium hyaluronate (Hyalgan), 20                                    eligible recipients, 1
   sodium hyaluronate (Supartz), 21                                    explanation of form items: form 18–3, 5–11
                          ®
   somatropin (Serostim ) for HIV-associated                           institutions for mental disease (IMD), 13
      wasting, 22–26                                                   medical and psychiatric services: TAR submission, 12
   streptokinase, 27                                                   mental health provider number, 12
   therapeutic injection benefits, 28                                  ordering TAR form 18–3, 3–4
   thyrotropin alfa (Thyrogen), 28                                     out-of-state providers: psychiatric inpatient services
                        ®
   tigecycline (Tygacil ), 29                                            guidelines, 1
                                ®
   tinzaparin Sodium (Innohep ), 29                                       authorization, 2–3
   tocilizumab (Actemra), 29-30                                        reimbursement rates, 14
                             ®
   treprostinill (Remodulin ), 30                                      reimbursement restrictions, 14
   ustekinumab (Stelara), 30                                           revenue codes, 13
   vancomycin, 31                                                      take-home drugs, 14
   velaglucerase alfa (VPRIV), 31                                      TAR appeals and fair hearing requests, 15
                           ®
   verteporfin (Visudyne ), 31                                         TAR submissions, 3
   visualization adjunct, 32
   vitamin B-12, 32
                         ®
   ziprasidone (Geodon ), 32
                              ®
   zoledronic acid (Reclast ), 33
   zoledronic acid (Zometa), 33




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
34 Section Titles/Headings Index
Inpatient Mental Health Services Program: Plan-                     Licensing and Certification for Inpatient Services,
 Authorization Directory, P2: IP inp ment pln, 1–9                   P2: IP licens ip
Intravenous or Intra-arterial Solutions: Administration                certified nurse assistant: recertification, 3
 Sets, P2: PH iv sol admin                                             competency evaluation program for nurse aides, 2
   individual components, 1                                            medical care evaluation (MCE) studies, 1
   separate components: administration sets, 1                      Licensing and Certification for Long Term Care,
   single product: administrations sets, 1                           P2: LTC licens ltc
Intravenous or Intra-arterial Solutions: Special Billing,              Facilities Certification
 P2: PH iv sol spec                                                        distinct-part hospital, 2
   authorized intravenous solutions, 4                                     medical care evaluation (MCE) studies, 4
   claims submission for intravenous solutions, 5                          special treatment program for the mentally
   code I documentation requirements, 4                                      disordered–developmentally disabled program, 2–3
   ingredients not on list of contract drugs, 4                     Licensing and Certification for Long Term Care,
   intravenous solutions of other "unlisted" drugs, 3                P2: LTC licens ltc (continued)
   intravenous solutions of "unlisted" antibiotics, 3                  Licensing
   multiple-ingredient injections, 3                                       change of ownership: 60-day prior notification, 1
   parenteral nutrition solutions: (TPN or                             Staff Certification
    hyperalimentation), 2                                                  certified nurse assistant: recertification, 6
   separately administered intravenous lipids, 2                           competency evaluation program for nurse aides, 7
   simple intravenous solutions, 1                                         course materials for nurse aides, 6
   sterile transfers, 3L                                                   physician recertification, 5
Leave of Absence and Bed Hold, P2: LTC leave                        Local Educational Agency (LEA), P2: LEA loc ed
   Acute Hospitalization                                               eligible students, 6
       bed hold qualifications, 4                                      exceptions to the free care requirement, 10
       leave of absence to an acute hospital and return to             inquiries, 1
         NF-B and return to acute hospital, 6–8                        overview of LEA, 1
       reserved bed arrangements, 4–5                                  supervising speech pathologist and/or audiologist, 19
   Developmentally Disabled (DD) Recipients
       bed hold reimbursement, 9
       summer camp leave, 9
   Leave of Absence
       leave of absence qualifications, 1
       LOA and bed hold general requirements, 3
       recipient failure to return from leave of absence, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 35
Local Educational Agency (LEA): A Provider's Guide,                 Local Educational Agency (LEA) Billing Codes and
 P2: LEA loc ed a prov                                               Reimbursement Rates, P2: LEA loc ed bil cd
   annual report requirements, 3                                       LEA services billing codes chart, 1–16
   Cost and Reimbursement comparison                                   reimbursement rates, 1
     schedule (CRCS), 4                                             Local Educational Agency (LEA) Billing Examples,
   LEAs responsible for maintaining evidence of                      P2: LEA loc ed bil ex
     practitioner qualifications, 4                                    billing tips, 1
   managed care plans, 6                                               "from-through" billing: two or more sessions on different
   models of service delivery for employed or                            dates of service, IEP student, 9–11
     contracted practitioners, 5                                       one session developmental assessment, non-IEP/IFSP
   provider enrollment, 1–2                                              student, 2–3
   provider responsibilities, 2–3                                      one session initial health assessment, IEP student, 7–8
   records retention, 7–8                                              one session occupational therapy, 2–3
   service and reimbursement report, 8                                 retroactive billing IEP student, 12–14
   support cost, 8                                                     two sessions of speech therapy on same date of service,
   where to submit annual reports, 4                                     IEP student, 4–6
Local Educational Agency (LEA) Billing and                          Local Educational Agency (LEA) Eligible Students,
 Reimbursement Overview, P2: LEA loc ed bil                          P2: LEA loc ed elig
   billing code list, 1                                                determining eligibility, 2–3
   billing reminders, 16                                               eligible students, 1
   claim submission and twelve-month billing limit, 15                 ineligible aid codes, 1
   claim submission: UB-04 claim form, 13                           Local Educational Agency (LEA):Individualized Plans,
   Computer Media Claims (CMC), 11                                   P2: LEA loc ed indiv
   free care and other health coverage requirements, 2–4               IEP/IFSP assessments, 1–2
   "from-through" billing, 15                                       Local Educational Agency (LEA) Rendering Practitioner
   ICD-9-CM codes, 14                                                Qualifications, P2: LEA loc ed rend
   IEP/IFSP assessments, 8                                             audiologists, 9
   initial and additonal treatment services, 9                         certified nurse Practitioners, 3
   introduction, 1                                                     certified public health nurses, 3
   managed care plans, 5                                               credentialed school counselors, 7
   medical transportation and mileage, 9                               credentialed school psychologists, 6
   modifiers, 10–11                                                    credentialed school social workers, 5
   practitioner services reimbursable to LEAs, 5
   restrictions, 1
   retroactive billing for TCM date of certification, 15
   retroactive billing from date of service, 15
   service limitations, 8
   treatment services billed in 15-minute increments, 9




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
36 Section Titles/Headings Index
Local Educational Agency (LEA) Rendering Practitioner               Local Educational Agency (LEA) Service: Nursing,
 Qualifications, P2: LEA loc ed rend (continued)                     P2: LEA loc ed serv nurs
   licensed audiologists, 8                                            nursing and school health aide services, 1–2
   licensed clinical social workers, 5                                 procedure codes/service limitations chart: nursing and
   licensed educational psychologists, 6                                   school health aide services, 5–6
   licensed marriage and family therapists, 6                          recommendations, 2
   licensed optometrists, 4                                            service limitations: annual, 4
   licensed physical therapists, 7                                     service limitations: daily, 4
   licensed physicians and psychiatrists, 4                            supervision requirements, 3
   licensed psychologists, 5                                           treatment services billed using 15-minute increments, 4
   licensed registered nurses, 3                                    Local Educational Agency (LEA) Service: Occupational
   licensed speech-language pathologists, 8                          Therapy, P2: LEA loc ed serv occu
   licensed vocational nurses, 3                                       initial and additional treatment services, 3
   program specialists, 9                                              occupational therapy, 1–2
   qualified LEA rendering practitioners, 1–2                          prescriptions, 2
   registered credentialed school nurses, 3                            procedure codes/service limitations chart: occupational
   registered occupational therapists, 7                                  therapy services, 4
   registered school audiometrists, 9                                  service limitations: annual, 3
   rendering practitioner qualifications, 2                            service limitations: daily, 3
   speech-language pathologists, 8                                     supervision requirements, 2
   trained health care aides, 4                                     Local Educational Agency (LEA) Service: Physical
Local Educational Agency (LEA) Service: Hearing,                     Therapy, P2: LEA loc ed serv phy
 P2: LEA loc ed serv hear                                              initial and additional treatment services, 3
   audiology services, 1–2                                             physical therapy, 1–2
   initial and additional treatment services, 6                        prescriptions, 2
   procedure codes/service limitations chart: audiology                procedure codes/service limitations chart: physical
     services, 7–8                                                       therapy services, 4
   referrals, 3                                                        service limitations: annual, 3
   service limitations: annual, 6                                      service limitations: daily, 3
   service limitations: daily, 6                                       supervision requirements, 2
   supervision rerquirements, 4–5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 37
Local Educational Agency (LEA) Service: Physician                   Local Educational Agency (LEA) Service: Targeted Case
 Billable Procedures, P2: LEA loc ed serv physician                  Management, P2: LEA loc ed serv targ
   initial and additional treatment services, 4                        coordinating TCM, 3
   physician/psychiatrist services, 1–2                                procedure codes/service limitations chart: targeted
   procedure codes/service limitations chart: physician                  case management, 5
     services, 5–7                                                     service limitations: annual, 4
   recommendations, 2                                                  service limitations: daily, 4
   service limitations: annual, 3                                      supervision requirements, 3
   service limitations: daily, 4                                       targeted case management services, 1–2
   supervision requirements, 3                                         TCM services billed using 15-minute increments, 4
Local Educational Agency (LEA) Service:                             Local Educational Agency (LEA) Service:
 Psychology/Counseling, P2: LEA loc ed serv psych                    Transportation (Medical), P2: LEA loc ed serv trans
   procedure codes/service limitations chart: psychology               medical transportation services, 1–2
    and counseling services, 6–9                                       procedure codes/service limitations chart: medical
   psychology and counseling services, 1–2                                transportation services, 3
   recommendations, 3                                                  service limitations: annual, 2–3
   service limitations: annual, 4                                   Local Educational Agency (LEA) Service: Vision
   service limitations: daily, 5                                     Assessments, P2: LEA loc ed serv vis
   supervision requirements, 4                                         optometry services, 1
Local Educational Agency (LEA) Service: Speech                         procedure codes/service limitations chart:
 Therapy, P2: LEA loc ed serv spe                                        vision assessments, 3
   initial and additional treatment services, 5                        recommendations, 2
   procedure codes/service limitations chart: speech                   service limitations: annual, 2
     therapy, 6–7                                                      service limitations: daily, 2
   referrals, 2–3                                                      supervision requirements, 2
   service limitations: annual, 5                                   Low Vision Aids, P2: VC low vision
   service limitations: daily, 5                                       Billing
   speech therapy, 1–2                                                     authorization, 4
   supervision requirements, 4                                             low vision examination, 2–3
                                                                           program coverage, 1
                                                                           required information, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
38 Section Titles/Headings Index
M                                                                   MCP: Prepaid Health Plan (PHP), P1: mcp pre
MCP: An Overview of Managed Care Plans,                                authorization, 2
 P1: mcp an over                                                       capitated/noncapitated clinics or center services, 5
   dental services, 2                                                  capitated/noncapitated drugs, 6–7
   eligibility verification/identification cards, 2                    capitated/noncapitated services, 3
   Health Care Options (HCO) contractor, 3                             excluded enrollment, 2
   managed care plan directory, 2                                      PHP plans, 1
   Office of the Ombudsman, 3                                          program information, 1
   specialty mental health services, 1                              MCP: Primary Care Case Management (PCCM),
MCP: Code Directory, P1: mcp code dir, 1–9                           P1: mcp prim
MCP: County Organized Health System (COHS),                            AIDS Healthcare Centers, 1–3
 P1: mcp cohs                                                          capitated services, 2
   authorization, 2                                                    excluded enrollment, 1
   capitated/noncapitated clinic or center services, 5                 noncapitated drugs, 4
   capitated/noncapitated drugs, 6–7                                   noncapitated services, 4
   capitated/non-capitated services, 2–5                               other services, 3
   COHS plans, 1                                                       PCCM plans, 1
MCP: Fee-For-Service/Managed Care (FFS/MC),                         MCP: Special Projects, P1: mcp spec
 P1: mcp ffs                                                           AIDS Health Care Foundation dba Positive Health Care
   contracting providers, 2                                               end stage renal disease pilot project:
   eligible recipients, 1                                                   VillageHealth and Fresenius, 7–9
   excluded enrollment, 1–2                                               Family Mosaic Project, 3–5
   recipient disenrollment, 2                                             capitated/noncapitated drugs, 5
MCP: Geographic Managed Care (GMC), P1: mcp gmc                           PACE, 1–3
   authorization, 3                                                       SCAN health plan, 5–7
   capitated/non-capitated clinic or center services, 6             MCP: Two-Plan Model, P1: mcp two plan
   capitated/noncapitated drugs, 7                                     capitated/noncapitated clinic or center services, 5
   capitated/noncapitated services, 4–6                                capitated/noncapitated drugs, 6–7
   eligible providers, 1                                               capitated/noncapitated services, 3–4
   eligible recipients, 1                                              excluded enrollment, 1–2
   emergency services, 3                                               program information, 1
   excluded enrollment, 2                                              where to submit claims, 7
   Sacramento GMC health plans, 3
   San Diego GMC health plans, 3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 39
Medical Supplies: An Overview, P2: DME PH mc sup                    Medical Supply Products: Gloves, Disposable, P2: DME
   authorization, 5                                                  PH mc sup prod glov
   claim information, 7                                                billing limitations, 1
   contracted medical supplies, 2                                      claim requirements, 1
   incontinence supplies, 5                                            reimbursable only for specified recipients, 1
   medicare covered service, 4                                        Gloves, Disposable, 1–20
   other health coverage documentation, 3                           Medical Supply Products: Miscellaneous, P2: DME PH
   program coverage, 1                                               mc sup prod misc
   provider requirements: dangerous medical devices, 4                 authorization, 1
   recipient eligibility requirements, 2                               documentation requirements, 1
   reimbursement, 6                                                    equipment related supplies, 1
   self-certification for other health coverage, 3                    Miscellaneous Products, 1–11
Medical Supplies: Billing Examples, P2: DME PH                      Medical Supply Products: Ostomy-Accessories/Skin
 mc sup ex                                                           Barriers, P2: mc sup prod ost ac
   billing tips, 1                                                     authorization, 1
   ostomy supplies: contracted, 2                                      contracted ostomy supplies claim requirements, 1
   attachment invoice requirements, 4                                  medicare billing required, 1
   catalog or price list requirements, 7                               non-contracted ostomy supplies, 1
Medical Supplies: Medicare Covered Services, P2: DME                  Ostomy Accessories, 1–36
 PH mc supp medi                                                    Medical Supply Products: Ostomy-One-Piece
   Medicare billing required, 1                                      Closed/Urinary Pouches, P2: mc sup
Medical Supply Products: Diabetic Supplies, P2: DME                  prod ost oneclos
 PH mc sup prod dia                                                    billing limitations, 1
        billing limitation, 1                                          contracted ostomy supplies claim requirements, 1
        diabetic control solution, 1                                   medicare billing required, 1
        medicare billing required, 1                                   non-contracted ostomy supplies, 2
 Diabetic Supplies,1–14                                               One-Piece Closed Pouches,1–41
                                                                    Medical Supply Products: Ostomy-One-Piece
                                                                     Drainable Pouches, P2: mc sup prod ost onedr
                                                                       billing limitation, 1
                                                                       contracted ostomy supplies claim requirements, 1
                                                                       medicare billing required, 1
                                                                       non-contracted ostomy supplies, 1
                                                                      One-Piece Drainable Pouches, 1–73




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
40 Section Titles/Headings Index
Medical Supply Products: Ostomy–Two-Piece                           Medical Supply Products: Tracheostomy–A thru F
 Drainable/Closed Pouches, P2: mc sup prod ost twodr                 Manufactures, P2: mc sup prod trach a
   billing limitations, 1                                             billing limitations, 1
   contracted ostomy supplies claim requirements, 1                   claim requirements, 1
   medicare billing required, 1                                       contracted tracheostomy supplies, 1
   non-contracted ostomy supplies, 1                                  MAC guarantee through independent medical only, 1
 Two-Piece Drainable Pouches, 1–61                                    medicare billing required, 1
Medical Supply Products: Ostomy–Two-Piece Extended                   Non-Contracted Tracheostomy Supplies, 1–31
 Wear Skin Barriers, P2: mc sup prod ost twoex                      Medical Supply Products: Tracheostomy–G thru M
   billing limitations, 1                                            Manufactures, P2: mc sup prod trach a
   contracted ostomy supplies claim requrements, 1                    billing limitations, 1
   medicare billing required, 1                                       claim requirements, 1
 Two-Piece Extended Wear Skin Barriers, 1–29                          contracted tracheostomy supplies, 1
Medical Supply Products: Ostomy–Two-Piece High                        MAC guarantee through independent medical only, 1
 Output/Urinary Pouches, P2: mc sup prod ost twohi                    medicare billing required, 1
   billing limitations, 1                                            Non-Contracted Tracheostomy Supplies, 1–32
   contracted ostomy supplies claim requirements, 1                 Medical Supply Products: Tracheostomy–N thru S
   medicare billing required, 1                                      Manufactures, P2: mc sup prod trach a
   non-contracted ostomy supplies, 1                                  billing limitations, 1
 Two-Piece High Output Pouches, 1–12                                  claim requirements, 1
Medical Supply Products: Ostomy–Two-Piece Standard                    contracted tracheostomy supplies, 1
 Wear Skin Barriers, P2: mc sup prod ost twostd                       MAC guarantee through independent medical only, 1
   billing limitations, 1                                             medicare billing required, 1
   contracted ostomy supplies claims requirements, 1                 Non-Contracted Tracheostomy Supplies, 1–21
   medicare billing required, 1                                     Medical Supply Products: Tracheostomy–T thru Z
 Two-Piece Standard Wear Skin Barrier, 1–32                          Manufactures, P2: mc sup prod trach a
                                                                      billing limitations, 1
                                                                      claim requirements, 1
                                                                      contracted tracheostomy supplies, 1
                                                                      MAC guarantee through independent medical only, 1
                                                                      medicare billing required, 1
                                                                     Non-Contracted Tracheostomy Supplies, 3–25




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 41
Medical Supply Products: Urologicals-Drainage Bags,                 Medical Supply Products: Urologicals– Intermittent
 P2: mc sup prod uro drain                                          Catheters - Manufacturers G thru M,
   billing limitations, 1                                            P2: mc sup prod uro int g
   medicare billing required, 1                                        authorization, 1
 Urological Drainage Bags, 1                                           billing limitations, 1
Medical Supply Products: Urologicals-External                          claim requirements, 1
 Catheters, P2: mc sup prod uro ext                                    medicare billing required, 1
   authorization, 1                                                   Contracted Intermittent Urinary Catheters, 2–25
   billing limitations, 1                                           Medical Supply Products: Urologicals– Intermittent
   medicare billing required, 1                                     Catheters - Manufacturers N thru Z,
 Urological External Catheters, 1                                    P2: mc sup prod uro int n
Medical Supply Products: Urologicals- Indwelling                       authorization, 1
 Catheters, P2: mc sup prod uro ind                                    billing limitations, 1
   billing limitations, 1                                              claim requirements, 1
   medicare billing required, 1                                        medicare billing required, 1
 Urological Indwelling Catheters, 1                                   Contracted Intermittent Urinary Catheters, 2–32
Medical Supply Products: Urologicals- Insertion Trays,              Medical Supply Products: Urologicals–Tubes, Clamps
 P2: mc sup prod uro insert                                          and Connectors, P2: mc sup prod uro tube
   billing limitations, 1                                              authorization, 1
   medicare billing required, 1                                        billing limitations, 1
 Urological Insertion Trays, 1                                         medicare billing required, 1
 Urological Irrigation Trays, 2                                       Tubes, Clamps and Connectors, 1–2
Medical Supply Products: Urologicals– Intermittent                  Medical Supply Products: Wound Care -Advanced
Catheters - Manufacturers A thru F,                                  Contracted, P2: mc sup prod woun adv con
 P2: mc sup prod uro int a                                             claim requirements, 1
   authorization, 1                                                   Advanced Wound Care, 1–61
   billing limitations, 1                                           Medical Supply Products: Wound Care -Advanced Non
   claim requirements, 1                                             Contracted, P2: mc sup prod woun adv non
   medicare billing required, 1                                        authorization, 1
 Contracted Intermittent Urinary Catheters, 2–60                       billing limitations., 1
                                                                       “by report”, 1
                                                                    Medical Supply Products: Wound Care -Bandages,
                                                                     Gauzes, Packing Strips, Eye Pads P2: mc sup prod
                                                                     woun band
                                                                       billing limitations, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
42 Section Titles/Headings Index
Medical Transportation–Air, P2: MTR mc tran air                     Medical Transportation–Ground, P2: MTR mc tran gnd
   Billing Information                                              (continued)
       dry run, 9                                                      Emergency Ground Medical Transportation
       patient on board miles, 8                                           emergency statement, 3
       supplies billed for unlisted air transportation, 8                  transportation to nearest hospital, 2
       trips with multiple recipients, 8                                   transportation to second facility, 2
       waiting time, 9                                                 General Information
   Emergency Air Medical Transportation                                    eligibility requirements, 1
       emergency coverage, 3                                               program coverage, 1
       emergency statement, 4                                          Non-Emergency Ground Medical Transportation
       out-of-state emergency restrictions, 3                              authorization, 4
       transportation by closest available provider, 3                     inter-facility transport – pediatric critical care, 4
       transportation to a second facility, 3                              non-emergency coverage, 4
       transportation to nearest hospital, 2                               prescription requirements, 5
   Non-Emergency Air Medical Transportation                                reimbursement, 8
       air medical transportation, 5                                       transport from acute care hospital to long term care
       helicopter transportation, 6                                          facility, 6
       prescription requirements, 6                                        transportation to adult day health care (ADHC)
       prior authorization, 5                                                centers, 7
       reimbursement, 7                                                    types of ground medical transportation, 9–11
Medical Transportation–Air: Billing Codes and                       Medical Transportation–Ground: Billing Codes and
 Reimbursement Rates, P2: MTR mc tran air cd                         Reimbursement Rates, P2: MTR mc tran gnd cd
   codes and rates, 1–2                                                codes and rates, 1–4
Medical Transportation–Air: Billing Examples,                       Medical Transportation–Ground: Billing Examples,
 P2: MTR mc tran air ex                                              P2: MTR mc tran gnd ex
   additional air mileage: modifier -Z1, 2–3                           billing tips, 1
   billing tips, 1                                                     emergency transport, 4–5
   emergency air transport, 2–3                                        non-emergency transport, 2–3
Medical Transportation–Ground, P2: MTR mc tran gnd
   Billing Information
       dry run, 15
       mileage, 14
       multiple trips for same recipient, 13
       night calls, 14
       round trips, 13
       transportation from and back to a hospital: place of
         service code 21, 13
       trips with multiple recipients, 12–13
       waiting time, 15




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
                                                                          Section Titles/Headings Index 43
Medicare-Covered Drugs, P2: PH medicare drugs, 1–2                  Medicare/Medi-Cal Crossover Claims: CMS-1500
Medicare/Medi-Cal Crossover Claims: CMS-1500,                        Billing Examples for Allied Health, P2: AUD CHR
 P2: AUD CHR DME MS MTR OAP PSY THP                                  DME MTR OAP PSY THP medi cr cms exa
 medi cr cms                                                           billing tips, 1
   Billing for Medicare Non-Covered, Exhausted or Denied               hardcopy billing examples, 1–3
    Services, or Medicare Non-Eligible Recipients                   Medicare/Medi-Cal Crossover Claims: CMS-1500
       billing tips: Medicare non-covered, exhausted or              Billing Examples for Medical Services,
         denied services, 17–18                                      P2: MS medi cr cms exm
       Medicare denied services, 16–17                                 hardcopy billing examples, 1–3
       Medicare documentation requirements, 19–20                   Medicare/Medi-Cal Crossover Claims:
       Medicare exhausted services, 15–16                            CMS-1500 Pricing
       Medicare non-covered services, 14                             Examples for Allied Health, P2: AUD CHR DME MTR
       Medicare non-eligible recipients, 19                          OAP PSY THP medi cr cms pra
       Medicare reimbursement, 14                                      crossover claim payment examples, 3–9
Medicare/Medi-Cal Crossover Claims: CMS-1500,                          payment on crossover claims, 1
 P2: AUD CHR DME MS MTR OAP PSY THP                                    payment on Medicare non-covered, exhausted or denied
 medi cr cms (continued)                                                 services, 1
   Charpentier Rebilling                                               Remittance Advice Details (RAD), 1–2
       billing tips: Charpentier rebills, 12–13
       Medi-Cal reimbursement, 9
       submission requirements, 10–12
       where to submit Charpentier rebills, 10
   Crossover Claims Inquiry Forms (CIFs)
       CIF for all crossover claims, 8
       reimbursement for beds and mattresses, 8
   Hardcopy Submission Requirements of Medicare
    Approved Services
       billing tips: part B services billed to part B
        carriers, 6–7
       part B services billed to part A intermediaries, 7–8
       part B services billed to part B carriers, 2–4
       psychiatric services for HCP-enrolled recipients, 5
       reimbursement to clinical nurse specialists, 5
       reimbursement to licensed clinical social workers, 5
       where to submit hardcopy crossover claims, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
44 Section Titles/Headings Index
Medicare/Medi-Cal Crossover Claims: CMS-1500                        Medicare/Medi-Cal Crossover Claims: Inpatient
 Pricing Examples for Medical Services,                              Services, P2: IP medi cr ip
 P2: MS medi cr cms prm                                               NPI used to bill Medicare, 1
   crossover claim payment examples, 3–9                              Reimbursement Guidelines
   payment on crossover claims, 1                                          cost sharing, 1
   payment on Medicare non-covered, exhausted                              restrictions affecting recipient in mental health
    or denied services, 1                                                   facitilies, 1
   Billing for Medicare Non-Covered, Exhausted or Denied                   comparative pricing, 2
    Services, or Medicare Non-Eligible Recipients                     Hardcopy Submission Requirements of Medicare
       Medicare non-eligible recipients, 20                             Approved Services
       Medicare reimbursement, 19                                          where to submit hard copy crossover claims, 2
   Crossover Claims Inquiry Forms (CIFs)                                   part A only services billed to part A
       CIF for all crossover claims, 18                                      intermediaries, 3
       CIF for Medicare adjustments, 18                                    part B-only services billed to part A
   Hardcopy Submission Requirements of Medicare                              intermediaries, 9
    Approved Services                                                      psychiatric services for HCP-enrolled recipients, 11
       Medicare documentation requirements, 14–18                          part A part B services billed to part A
       NPI used to bill Medicare, 1                                          intermediaries, 12
       part A and part B services billed to part A                         split billing, 13
        intermediaries, 12                                                 medicare documentation requirements, 14
   Patient Liability for Medi-Cal Payment for Automatic             Medicare/Medi-Cal Crossover Claims: Inpatient
    Submissions                                                      Services, P2: IP medi cr ip (continued)
       share of cost (patient liability), 20                          Crossover Claims Inquiry Forms (CIFs)
       deductible/coinsurance reconcilaition, 21                           CIF for all crossover claims, 18
                                                                           CIF for Medicare adjustments,18
                                                                      Billing for Medicare Non-Covered, Exhausted or
                                                                        Denied Services, or Medicare Non-Eligible Recipients
                                                                           Medicare reimbursement, 19
                                                                           Medicare non-eligible recipients, 20
                                                                       Patient Liability for Medi-Cal Payment for Automatic
                                                                        Submissions
                                                                           share of cost (patient liability) ,20
                                                                           deductible/coinsurance reconciliation, 21




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 45
Medicare/Medi-Cal Crossover Claims: Inpatient                       Medicare/Medi-Cal Crossover Claims: Long Term Care
 Services, Billing Examples, P2: IP medi cr ip ex                    Billing Examples, P2: LTC medi cr ltc ex
  hardcopy billing examples, 1                                         billing Medi-Cal for part A services billed to a part A
   Medicare lifetime reserve (LTR) days                                  contractor, 2–4
    coinsurance, 15–17                                                 billing Medi-Cal for part B overlapping dates of service,
   part A benefits exhausted, 5–7                                        8–9
   part A payment, 2–4                                                 billing Medi-Cal for part B services billed to a part A
   part B-only eligibility, 8–10                                         contractor, 5–7
   split billing: more than 22 line items with part B                  billing tips, 1
    payment, 11–14                                                     hard copy billing examples, 1
Medicare/Medi-Cal Crossover Claims: Long Term Care,                 Medicare/Medi-Cal Crossover Claims: Outpatient
 P2: LTC medi cr ltc                                                 Services, P2: AID CAH DIA HER HOM HOS REH
   Automatic Claim Submissions: Additional Information               medi cr op
       deductible/coinsurance reconciliation, 3                        Billing for Medicare Non-Covered, Exhausted or Denied
       NPI used to bill Medicare, 4                                      Services, or Medicare Non-Eligible Recipients
       share of cost (patient liability), 4                                billing tips: Medicare non-covered, exhausted or
   Billing for Medicare Non-Covered, Exhausted or Denied                     denied services, 26–27
    Services, or Medicare Non-Eligible Recipients                          Medicare denied services, 25–26
       Medicare reimbursement, 8                                           Medicare documentation requirements, 28–30
       Medicare non-covered services, 8                                    Medicare exhausted services, 24–25
       Medicare non-eligible recipients, 9                                 Medicare non-covered services, 23
       Medicare documentation requirements, 9–12                           Medicare non-eligible recipients, 28
   Crossover Claims Inquiry Forms (CIFs)                                   Medicare reimbursement, 23
       CIF for all crossover claims, 8                                 Charpentier Rebilling
       CIF for Medicare adjustments, 8                                     billing tips: Charpentier rebills, 21–22
Medicare/Medi-Cal Crossover Claims: Long Term Care,                        Medi-Cal reimbursement, 18
 P2: LTC medi cr ltc (continued)                                           submission requirements, 19–21
   Hard Copy Submission Requirements for Medicare                          where to submit Charpentier rebills, 19
    Approved Services                                                  Crossover Claims Inquiry Forms (CIFs)
       part A services billed to part A contractor, 2–4                    CIF for all crossover claims, 17
       part B services billed to part A, contractor 5–7                    reimbursement for beds and mattresses, 17
       where to submit hard copy crossover claims, 5
   Medicare Eligibility
       authorization, 3
       part A and part B, 2–3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
46 Section Titles/Headings Index
Medicare/Medi-Cal Crossover Claims: Outpatient                      Medicare/Medi-Cal Crossover Claims Overview,
 Services, P2: AID CAH DIA HER HOM HOS REH                           P1: medicare
 medi cr op (continued)                                                Billing Guidelines
   Hardcopy Submission Requriements of Medicare                            automatic crossover claims, 9
    Approved Services                                                      claims requiring hard copy billing, 11
       billing tips: part B services billed to part A                      Computer Media Claims, 6
         intermediaries, 12                                                electronic billing, 8
       billing tips: part B services billed to part B carriers,            general crossover information, 6
         4–5                                                               medical supplies, 7
       part B services billed to part A intermediaries, 6–11               Medicare and Medi-Cal dual eligibility, 7
       part B services billed to part B carriers, 2–3                      Medicare covered drugs, 8
       psychiatric services for HCP-enrolled recipients, 4                 part A and part B coverage, 7
       where to submit hardcopy crossover claims, 2                        part A coverage only, 6
Medicare/Medi-Cal Crossover Claims: Outpatient                             part B coverage only, 7
 Services, P2: AID CAH DIA HER HOM HOS REH                                 prior authorization, 8
 medi cr op (continued)                                                    Share of Cost, 8
   Special Billing Instructions                                            'zero pay' crossovers, 10
       dialysis: part B services, 14                                   Crossover Programs
       Rural Health Clinics and Federally Qualified Health                 Qualified Medicare Beneficiary (QMB) program, 12
         Centers and Indian Health Services Memorandum                 Health Maintenance Organization (HMO) Medicare
         of Agreement (IHS/MOA) Clinics, 13–14                           Advantage Plans
       split billing: more than 15 line items for part B                   plan overview. 3
         services billed to part A intermediaries, 15–16               Legal Constraints
Medicare/Medi-Cal Crossover Claims: Outpatient                             circumstances changing Medicare provider
 Services Billing Examples, P2: AID CAH HER HOM                              number, 15
 HOS REH medi cr op ex                                                     deductibles and coinsurance, 2
   billing tips, 1                                                         Health Maintenance Organization (HMO), 3
   hardcopy billing examples, 1–16                                         Medi-Cal reimbursement, 1
Medicare/Medi-Cal Crossover Claims: Outpatient                             part B premiums, 2
 Services Medi-Cal Pricing Examples, P2: AID CAH                           payments received from Medi-Cal recipients, 2
 HER HOM HOS REH medi cr op pr                                             provider master file inquiries, 15
   crossover claim payment examples, 3–11                                  where to submit updates, 15
   payment on crossover claims, 1                                      Medicare Summary of Services
   payment on Medicare non-covered, exhausted or denied                    Medicare covered services, 4–5
    services, 1                                                            types of Medicare eligibility, 6
   Remittance Advice Details (RAD), 1–2                               National Provider Identifier (NPI) Updates
                                                                           inaccurate or missing NPI, 13




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 47
Medicare/Medi-Cal Crossover Claims: Pharmacy                        Medicare/Medi-Cal Crossover Claims:
 Services, P2: medi cr ph                                            Pharmacy Services Medi-Cal Pricing Examples,
   Billing for Medicare Non-Covered, or Denied                       P2: PH medi cr ph pr
    Services, or Medicare Non-Eligible Recipients                      crossover claim payment examples, 3–14
        billing tips: Medicare non-covered, exhausted or               payment on crossover claims, 1
         denied services, 20-21                                        payment on Medicare non-covered, exhausted or denied
        Medicare denied services, 19-20                                 services, 1
        Medicare documentation requirements, 22–25                     Remittance Advice Details (RAD), 1–2
        Medicare non-covered services, 18                           Medicare/Medi-Cal Crossover Claims: UB-04, P2: CHR
        Medicare non-eligible recipients, 22                         DME MTR OAP PSY THP medi cr ub
        Medicare reimbursement, 18                                     Hardcopy Submission Requirements of Medicare
   Charpentier Rebilling                                                 Approved Services
        billing tips: Charpentier rebills, 16–17                           billing tips: part B services billed to
        Medi-Cal reimbursement, 18                                           part A intermediaries, 7
        submission requirements, 13–16                                       part B services billed to part A intermediaries, 1–6
        where to submit Charpentier rebills, 13                            split billing: more than 15 line items for part B
   Crossover Claims Inquiry Forms (CIFs)                                     services billed to part A intermediaries, 8-9
        CIF for all crossover claims, 11                                   where to submit hardcopy crossover claims, 1
        reimbursement for beds and mattresses, 11                   Medicare/Medi-Cal Crossover Claims: UB-04
   Hardcopy Submission Requirements for Medicare                     Billing Examples, P2: CHR DME MTR OAP
    Approved Services                                                PSY THP medi cr ub ex
        billing tips: part B services billed to part A                 billing tips, 1
         intermediaries, 9–10                                          hardcopy billing examples, 1–7
        billing tips: part B services billed to part B carriers,       split billing: more than 15 line items for Part B
         4–5                                                             services billed to Part A intermediaries, 8–9
        part B services billed to part A intermediaries, 6–8
        part B services billed to part B carriers, 2–3
       where to submit hardcopy crossover claims, 2
Medicare/Medi-Cal Crossover Claims: Pharmacy
 Services Billing Examples, P2: medi cr ph ex
   billing tips, 1
   hardcopy billing examples, 1–17




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
48 Section Titles/Headings Index
Medicare/Medi-Cal Crossover Claims: Vision Care,                    Medicare Non-Covered Services: Charts Introduction,
 P2: VC medi cr vc                                                   P2: AID AUD CAH DIA DME HER HOM HOS MS MTR
   Billing for Medicare Non-Covered or Denied Services,              OAP PSY REH THP VC medi non cha
     or Medicare Non-Eligible Recipients                               codes excluded from list, 1
       billing tips: medicare non-covered or denied                    facility charges and services: dental oral surgery, 1
         services, 13–14                                               Medicare Procedures: Medi-Cal Code Correlation List, 1
       medicare reimbursement, 11                                   Medicare Non-Covered Services: CPT-4 Codes,
       medicare non-covered services, 11                             P2: CAH DIA MS VC medi non cpt, 1
       medicare denied services, 12                                 Medicare Non-Covered Services: HCPCS Codes,
       medicare non-eligible recipients, 14                          P2: AID AUD CAH DIA DME HER HOM HOS MS MTR
       medicare documentation requirements, 14–15                    OAP PH PSY REH THP VC medi non hcp 1–3
   Charpentier Rebilling                                            Medicare Procedures: Medi-Cal Code Correlation List,
       billing tips: Charpentier rebills, 10                         P2: CAH MS MTR OAP medi pro med, 1
       Medi-Cal reimbursement, 7–8                                  Medicine, P2: CAH GM IP medne
       submission requirements, 8–10                                   esophageal acid reflux testing, 7
       where to submit charpentier rebills, 8                          Extracorporeal Membrane Oxygenation (ECMO), 4–5
   Crossover Claims Inquiry Forms (CIFs)                               Hyperbaric Oxygen Therapy, 1–3
       CIF for all crossover claims, 6                                 inhaled nitric oxide, 6
   Hard Copy Submission Requirements for Medicare                      Negative Pressure Wound Therapy (NPWT)
     Approved Services                                                 Devices, 10–11
       billing tips: part B services billed to part                    Pulsed Irrigation Enhanced Evacuation (PIEE), 7–8
         B carriers, 5–6                                               therapeutic phlebotomy, 6
       part B services billed to part B carriers, 2–4                  vitiligo, 7
       where to submit hard copy crossover claims, 2                Medicine: Neurology and Neuromuscular,
Medicare/Medi-Cal Crossover Claims: Vision Care                      P2: CAH GM medne neu
 Billing Examples, P2: VC medi cr vc ex                                central nervous system assessments and tests, 6
   billing tips, 1                                                     electromyography and nerve conduction test
   hard copy billing examples, 1–3                                      certification, 6
Medicare/Medi-Cal Crossover Claims: Vision Care                        electromyography (EMG), 5
 Medi-Cal Pricing Examples, P2: VC medi cr vc pr                       evoked response testing, 4–5
   crossover claim payment examples, 3–8                               nerve conduction, 5
   payment on crossover claims, 1                                      neurological monitoring, 5
   payment on medicare non-covered, exhausted or denied                polysomnography, 1–3
     services, 1
   Remittance Advice Details (RAD), 1–2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 49
Medicine: Non-Invasive Vascular Diagnostic Studies,                 Modifiers, P2: MS modif
 P2: CAH GM medne non                                                  claim completion tip, 3
  Non-invasive Vascular Diagnostic Studies, 1–3                        electroencephalogram, 3
Medicine: Otorhinolaryngologic Services,                               fetal stress/non-stress testing, 3
 P2: CAH GM medne oto                                                  place of service and payment percentages: exception
   auditory evoked potentials, 1                                        modifiers, 1
   electronystagmography, 1–2                                          radiology/pathology, 2
   fiberoptic endoscopic evaluation, 4                                 vestibular function tests and Non-invasive Vascular
   rhinomanometry, 1                                                    Diagnostic Studies, 3
   swallowing evaluation (CPT-4 code 92610), 2–3                    Modifiers for Outpatient Services,
   tympanometry, 1                                                   P2: AID CAH DIA REH modif op
Medicine: Pulmonary, P2: CAH GM medne pul                              electroencephalogram, 2
   aerosol, nebulizer, MDI, IPPB demonstration, 4                      physicians/podiatrists in surgical clinics, emergency
   chest physical therapy, 4                                            rooms and hospital outpatient departments:
   Pulmonary Function Tests: reimbursement                              medical/surgical procedures exception modifiers, 1
     guidelines, 1–3                                                   radiology/pathology, 2
   respiratory care practitioner services, 6–9                         vestibular function tests and non-invasive vascular
Medicine: Telemedicine, P2: CAH GM medne tele                           diagnostic studies (NVDS), 2
   guidelines, 1–3                                                  Modifiers Used With Procedure Codes,
   interactive telemedicine reimbursable services, 4–6               P2: AID CAH DIA MS REH modif used
   store-and-forward guidelines, 7                                     E&M codes and modifiers, 3
Mental Disease Institutions Directory,                                 HCPCS, CPT-4 medicine codes and modifiers, 4–10
 P2: CAH LTC mental, 1–2                                            Modifiers Used With Vision Care Procedure Codes,
Minor Consent Program, P2: CAH IP MS VC minor                        P2: VC modif used vc
   aid codes and service restrictions, 2                               allowable modifiers, 2–4
   claim completion, 3                                                 codes or code range, 1
   diagnosis codes, 3                                                  modifiers for excluded optional benefits exemptions, 1–2
   reimbursable services, 1                                            required modifiers, 1
Modifiers: Approved List, P2: AID AUD CAH DIA DME                      service or procedure, 1
 HOM LEA MS MTR OAP REH THP VC modif app, 1–24
   discontinued modifiers, 1
   modifier overview, 1
   national correct coding initiative, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
50 Section Titles/Headings Index
Multipurpose Senior Services Program (MSSP),                        Non-Injectable Drugs,
 P2: MSS multi sen                                                   P2: CAH DIA MS REH non inject
   Client Information                                                  albuterol, 3
       client eligibility, 2                                           azithromycin (Zithromax), 2
       client enrollment limits, 2                                     capsaicin patch, 4
   Home and Community-Based Services                                   dornase alfa, 3
       background, 1                                                   formoterol fumarate (perforomist™), 4
   Provider Information                                                ganciclovir long-acting implant, 1–2
       billing MSSP, 3                                                 granisetron (oral tablets), 3
       waiver agency payment, 2                                        histrelin vantas, 3
       waiver providers, 2                                             histrelin supprelin LA, 3
   Special Billing Instructions                                        testosterone pellet (testopel), 4
       "from-through" billing, 3                                       topotecan (hycamtin®), 4
Multipurpose Senior Services Program (MSSP) Billing                 Non-Physician Medical Practitioners (NMP),
Codes, P2: MSS multi sen cd                                          P2: CAH MS REH non ph
   waiver services, 1-7                                                Certified Nurse Midwife
Multipurpose Senior Services Program (MSSP) Billing                        billing and reimbursements, 16
 Example, P2: MSS multi sen ex                                             CNM enrollment, 16
   billing MSSP services over one month, 2–4                               covered services, 17–19
   billing tips, 1                                                         medicare/medi-cal eligiblity recipients, 20
                                                                           primary care defined, 14
N                                                                          supervision requirements, 14
Newborn Hearing Screening Program                                      Nurse Practitioners
 P2: AUD CAH GM IP REH THP newborn                                         billing and reimbursements, 7
   Introduction                                                            covered services, 8–10
       outpatient infant hearing screening providers, 2                    NP enrollment, 7
       program review, 1                                                   primary care defined, 5
       referral for rescreening, 1–2                                       supervision requirements, 5
   Reimbursement Requirements                                          Nurse Practitioners Board Certified Speciality
       authorization, 3                                                    billing and reimbursements, 13
       billing, 3                                                          certified nurse practioner provider, 12
       certified service providers, 4                                      provider enrollment, 12
       medical justification required, 4                               Physician Assistants
                                                                           billing and reimbursements, 3
                                                                           covered services, 3
                                                                           PA enrollment, 2
                                                                           supervision requirements, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 51
Non-Physician Medical Practitioners (NMP) Billing                   Obstetrics: Revenue Codes and Billing Policy,
 Example: CMS-1500, P2: MS non ph cms                                P2: IP ob rev
   billing tips, 1                                                     contract/non-contract hospitals, 1
   NMP-rendered services, 1–2                                          OB/newborn revenue chart, 2–9
Non-Physician Medical Practitioners (NMP) Billing                      per diem hospitals, 1
 Example: UB-04, P2: CAH REH non ph ub                                 per discharge hospitals, 1
   billing tips, 1                                                  Obstetrics: UB-04 Billing Examples for Inpatient
   CNM-rendered services, 2–3                                        Services, P2: IP ob ub ex
                                                                       bilateral procedures, 6
                                                                       billing tips, 1
O                                                                      contract OB per diem hospital: cesarean delivery of
OBRA and IRCA, P1: obra                                                 acutely sick baby, 2–7
   aid codes: covered services, 2                                      contract OB per diem hospital: well baby TAR-free
   aid codes: recipient types, 1–2                                      period, 29–32
   emergency medical conditions definition, 3                          contract OB per discharge hospital: cesarean delivery of
   emergency or pregnancy-related medical services:                     acutely sick baby, 8–11
    covered benefits, 3                                                multiple births of twins with differing dates of birth,
   Medicare/Medi-Cal crossovers, 5                                      18–24
   non-emergency and PHP services, 4                                   non-contract hospital in an open area: cesarean delivery
   pregnancy-related services, 5                                        of acutely sick baby, 12–17
Obstetrics: Revenue Codes Billing Instructions,                        vaginal delivery prior to hospital admission, 25–28
 P2: IP ob rev instr                                                Occupational Therapy, P2: ADU REH THP occu
   billing tips, 21                                                    eligibility requirements, 1-2
   index for samples, 1                                                initial and six-month evaluations, 3
   sample case 1, 2–3                                                  occupational therapy, case consultation and report, 4
   sample case 2, 4–5                                                  prescription requirements, 1–3
   sample case 3, 6–7                                                  program coverage, 1
   sample case 4, 8–9                                                  speech generating devices (SGD), 4
   sample case 5, 10–11                                                where to submit TARs, 3–4
   sample case 6, 12–13
   sample case 7, 14–15
   sample case 8, 16–17
   sample case 9, 18–19




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
52 Section Titles/Headings Index
Occupational Therapy: Billing Codes and                             Ophthalmology: Diagnosis Codes,
 Reimbursement Rates, P2: ADU REH THP occu cd                        P2: CAH GM ophthal cd 1
   codes and rates, 1                                               Optional Benefits Exclusion, P2: ACU ADU AUD CAH
Occupational Therapy Billing Example: CMS-1500,                      CHR DME GM HOM IP LTC OAP OB PH PSY THP
 P2: THP occu exc                                                    opt ben exc, 1–20
   billing tips, 1                                                     Acupuncture, Adult Day Health Care Centers,
   follow-up visit, 2–3                                                Audiology, Chiropractice, Clinics and Hospitals,
Occupational Therapy Billing Example: UB-04,                           Podiatry, Psychology and Speech Therapy Services
 P2: ADU REH occu exu                                                  Providers
   billing tips, 1                                                      additional policy and exemptions, 6
   follow-up visit, 2–3                                                 audiology exemptions, 7
Once-in-a-Lifetime Procedure Codes,                                     billing and TAR requirements, 7
 P2: CAH MS once, 1–5                                                   podiatry exemptions, 7
Ophthalmology, P2: CAH GM ophthal                                       psychology exemptions, 7
   bevacizumab (Avastin), 5                                            additional general criteria information, 4
   "by report" procedures, 6                                           affected provider types, 2
   cataract surgery supplies, 11                                       exemptions, 2
   computerized corneal topography, 4                                  FQHC, RHC and IHS
   contact lenses, 10                                                   additional policy and exemptions, 15–20
   correct claim form, 1                                               Incontience Creams and Washes Products Providers
   date appliance delivered, 12                                         additional policy and exemptions, 10
   determination of refractive state, 7                                Non Contract Inpatient Hospital Providers
   dexamethasone intravitreal implant (Ozurdex), 12                     policy, 13
   diagnosis codes, 1–6                                                Non-Emergency Medical Transportation Providers
   diagnostic drugs, 7                                                  policy, 14
   E&M codes not reimbursable with eye                                 Optical Service
     examination services, 8                                           additional policy and exemptions, 11
   fluocinoione acetonide intravitreal implant                         optional benefits excluded from coverage, 1
               ™
      (Retisert ), 11
   hardcopy billing crossover claims, 9
   interim examination, 8
Ophthalmology, P2: CAH GM ophthal (continued)
   Medicare covered services, 9
   Medicare non-covered, 9
   modifiers, 1
   ocular prosthesis, 11
   ophthalmic diagnostic imaging: billing restrictions, 3
   ranibizumab (Lucentis), 5
   retisert, 12
   routine examinations, 7
   tonometry, 7
   unilateral and bilateral, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 53
Orthotic and Prosthetic Appliances,                                 Orthotic and Prosthetic Appliances: Billing Examples,
 P2: OAP PH ortho                                                    P2: OAP PH ortho ex
   additional appliances, 7                                            bilateral appliances, 6–7
   authorization, 2–3                                                  billing tips, 1
   "by report" requirements, 8                                         custom-made device, 4–5
   cranial remolding orthoses, 9-10                                    orthosis repair, 2–3
   custom-made items, 6                                             Orthotics and Prosthetics: Frequency Limits for
   custom-made orthopedic shoes, 12                                  Orthotics, P2: DME OAP PH THP ortho cd fre1 1–4
   compression stockings, 14                                        Orthotics and Prosthetics: Frequency Limits for
   eligibility requirements, 1                                       Prosthetics, P2: DME OAP PH THP ortho cd fre2 1–3
   helmets, 8                                                       Other Health Coverage (OHC), P2: oth hlth
   infant spiral immobilizer, 15                                       billing Medi-Cal after OHC, 1-2
   modifier requirements, 2                                            delayed insurance response, 4
   prescription requirements, 1                                        HMO denial letters, 5
   program coverage, 1                                                 Kaiser denial letters, 5–6
   provider types authorized to bill for O & P appliances, 1           Long Term Care recipients: COV Code "L", 8
   reciprocating gait orthoses, 15-16                                  medical supply claims: OHC documentation, 1
   reimbursement, 4–5                                                  Medi-Cal Remittance Advice Details, 4
   removal soft interface, 17                                          Medicare and OHC, 2
   repair or maintenance of O&P, 5                                     Medicare drug coverage for NF-B patients – part A
   stock orthopedic and conventional shoes, 11                          benefits for Long Term Care, 7
   taxable orthotic procedures, 14                                     Medicare Part C recipients, 1
   therapeutic diabetic shoes and inserts, 13-14                       OHC cost-sharing, 3
   ultalight prosthetics, 7                                            OHC EOB or denial letter: documentation required by
   undeliverable custom-made items, 6                                   Medi-Cal, 2
Orthotic and Prosthetic Appliances: Billing Codes and                  Pharmacy: self-certification for OHC, 8
 Reimbursement Rates–Orthotics,                                        prescription drugs for Long Term Care recipients: COV
 P2: DME OAP PH THP ortho cd1                                           Code "P", 7
   codes and rates, 1–27                                               when to bill OHC, 3
Orthotic and Prosthetic Appliances: Billing Codes and                  Other Health Coverage (OHC) Codes Chart, P1: other
 Reimbursement Rates–Prosthetics,                                      billing OHC before Medi-Cal, 3
 P2: DME OAP PH THP ortho cd2                                          COV code explanation, 4
   codes and rates, 1–25                                               eligibility verification, 2
                                                                       function of OHC and COV codes, 4
                                                                       locating recipient's OHC information, 3
                                                                       nondiscrimination, 2
                                                                       OHC and COV code charts, 5–6
                                                                       OHC code explanation, 4
                                                                       POS/AEVS: multiple insurer messages, 4
                                                                       reporting OHC, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
54 Section Titles/Headings Index
Other Health Coverage (OHC): CPT-4 and HCPCS                        Pathology: Billing and Modifiers, P2: CAH MS path bil
 Codes, P2: AUD MS MTR OP oth hlth cpt                                billing for reference clinical laboratories with modifier
   recipients with OHC coverage, 1–2                                     90, 3
   recipients with OHC coverage through an HMO, 3                     billing method guidelines. 1
Other Health Coverage (OHC) Guidelines for Billing,                   billing same lab procedure more than once
 P1: other guide                                                         on same day, 13
   cost-avoided OHC and HMO coverage codes, 1                          breast and ovarian cancer gene sequence analysis:
   HMO coverage, 3                                                        HCPCS code S3820, 15–16
   non-restricted OHC codes, 2                                         clinical laboratory improvement amendments (CLIA)
   OHC code "A"–outside HMO service area, 2                               certification & billing for pathology, 10
   OHC code "F"–from a Medicare HMO, 2                                 criteria for one certificate for mutiple sites, 12
Other Health Coverage (OHC) Guidelines for Billing,                    diagnosis code requirement, 1
 P1: other guide                                                       electronic billing of laboratory services, 13
   cost-avoided OHC and HMO coverage codes, 1                          gene expression profiling HCPCS code S3854, 14
   HMO coverage, 3                                                     KRAS mutation analysis testing: HCPCS
   non-restricted OHC codes, 2                                             Code S3713, 17
   OHC code "A"–outside HMO service area, 2                            laboratory codes: not split-billable, 4–5
   OHC code "F"–from a Medicare HMO, 2                                 laboratory codes: split billable, 3
   OHC code "L"–dental coverage, 3                                     modifiers, 2
   OHC code "N"–no OHC, 3                                              procedures subject to proficiency testing, 11
Pathology: An Overview of Enrollment and Proficiency                   split billing guidelines, 1
 Testing Requirements, P2: CAH DIA MS path an over                     waived laboratory codes, 6–9
   CLIA number: billing for pathology, 1–2                          Pathology Billing Example: CMS-1500,
   CMS/CLIA Compliant Laboratory Services, 9                         P2: MS path bil cms
   laboratory categories of service, 9                                 billing single lab procedure more than once on same
   laboratory proficiency testing requirements, 4–7                      day, 2
   laboratory services reservation system, 8                        Pathology Billing Examples: UB-04
   provider enrollment, 3–4                                          P2: CAH DIA path bil ub
                                                                       billing same lab procedure more than once on same
                                                                         day, 2-4
                                                                       laboratory tests performed by unaffiliated lab, 5–7




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
                                                                          Section Titles/Headings Index 55
Pathology: Chemistry, P2: CAH DIA MS path chem                      Pathology: Immunology, P2: CAH MS path immun
   amniotic fluid detection testing, 5                                 extractable nuclear antigen antibody, 1
   billing exceptions, 2                                               H1N1 testing: Code 87798, 1
   blood glucose tolerance billing policy, 4                           hepatitis A antibody testing: codes 86708 and 86709, 1
   chorionic gonadotropin, 6                                           human epididymis protein, 1
   cyanocobalamin (vitamin B-12) test, 1–3                             QuantiFERON-TB blood test, 2–3
   ferritin test, 3                                                 Pathology: Microbiology, P2: CAH MS path micro
   gonadotropin: follicle stimulating hormone, 4                       antimicrobial susceptibility drug testing,
   Helicobacter pylori testing, 1                                        CPT-4 code 87190, 4
   immunoassay for tumor antigen, 7                                    CPT-4 codes 87076 and 87077, documentation
   myeloperoxidase, 6                                                    required, 4
   prolactin level testing, 5                                          CPT-4 code 87205, 87206 or 87210, documentation
   serum folic acid test, 3                                              required, 4
   thyroxine, 6                                                        CPT-4 codes 87905, 4
   transfusion medicine, 7                                             cultures and sensitivity studies, 1
Pathology: Cytopathology, P2: CAH MS path cyto                         HCPCS II codes: Q0111, Q0112 and Q0113, 5
   fine needle aspirates, 2                                            hepatitis C genotype testing, 7
   Pap smear tests, 1–2                                                human immunodeficiency virus (HIV) drug testing
Pathology: Drug Testing, P2: CAH MS path drug                          resistance, 8–10
   CLIA wavied test, 2                                                 infectious agent detection, 2
   drug screening tests, 1–2                                           microbiology procedures, 5
Pathology: Blood Collection and Handling,                              trofile testing, 10
 P2: CAH DIA MS path blood                                          Pathology: Mol1ecular Diagnostics,
   automated hemogram (CBC), 4                                       P2: CAH MS path molec
   blood counts and components, 3                                     genetic testing, 2
   blood specimens–collection and handling, 1–3                       KRAS mutation analysis testing: HCPCS code S3713, 2
   lead screening counseling with blood draw for                       molecular diagnostic tests, 1
     children, 5-6                                                     prenatal cystic fibroses screening, 1
   reticulocyte count flow cytometry, 4
Pathology: Blood Collection and Handling Billing
 Examples: CMS-1500, P2: CAH DIA MS path blood ex
   billing tips, 1
   blood specimens and collections (99000), 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
56 Section Titles/Headings Index
Pathology: Organ or Disease-Oriented Panels,                        Payment Request for Long Term Care (25-1):
 P2: CAH MS path organ                                               Submission and Timeliness Instructions,
   acute hepatitis panel, 5                                          P2: LTC pay ltc sub
   automated chemistry tests and organ or disease-oriented             claims over one year old, 3–6
     panels, 1–4                                                       late billing instructions, 2
   basic metabolic panel, 6                                            six-month billing limit, 1
   comprehensive metabolic panel, 7                                    where to submit claims, 1
   general health panel, 4                                          Payment Request for Long Term Care (25-1):
   hepatic function panel, 5                                         Tips for Billing, P2: LTC pay ltc tips
   lipid panel test (CPT-4 code 80061), 8                              bed hold reminders, 3
   obstetrical panel, 6                                                common billing errors, 1–2
   renal function panel, 8                                             field completion reminders, 3
Pathology: Surgical, P2: CAH MS path surg                              paper claim form requirements, 4
   prostate biopsy, 4                                               Pediatric Day Health Care (PDHC)–Early and
   reimbursable codes, 1–4                                           Periodic Screening, Diagnosis and Treatment,
Pathology: Urinalysis, P2: CAH MS path urin                          P2: HOM ped
   pregnancy testing code, 2                                           authorization, 3–5
   reimbursable codes, 1                                               billing process, 5
Patient Plans of Care for Inpatient Facilities,                        health care plans (HCPs), 5
 P2: IP patient ip                                                     program requirements, 1–3
   patient plans of care, 1–4                                          recipient eligibility, 1
Patient Plans of Care for Long Term Care,                              service code and reimbursement rate, 5
 P2: LTC patient ltc
   nursing facility level A written plan of care, 3
   nursing facility level B written plan of care, 2
   requirements, 1
Payment Request for Long Term Care (25-1)
 Completion, P2: LTC pay ltc comp
   explanation of form items, 3–14
   required claim form items, 14




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 57
Percent Programs, P1: percent                                       Pharmacy Claim Form (30-1) Completion,
   100 Percent Program                                               P2: PH pcf30-1 comp
      aid codes, 7                                                     emergency certification statement, 16
      child: continuous inpatient care beyond 19th                     explanation of form items, 3–16
       birthday, 7                                                  Pharmacy Claim Form (30-1) Examples,
      eligibility requirements: family income, 6                     P2: PH pcf30-1 ex
      emergency services for children with aid codes 7C                billing tips, 1
       and 8T, 8                                                       code 1 restricted drug, 4-5
      ineligible children, 6                                           compounded prescription, 2
      Medicare/Medi-Cal crossovers, 7                                  late billing, 2-3
      non-covered services, 8                                          medical supplies, 8-9
   133 Percent Program                                                 other health coverage, 6-7
      aid codes, 5                                                  Pharmacy Claim Form (30-1): Special Billing
      child: continuous inpatient care beyond sixth                  Instructions, P2: PH pcf30-1 spec
       birthday, 5                                                     compound pharmacy billing, 2–3
      eligibility requirements, 4                                      compounding fees, 4
      emergency services for children with aid codes 74                drugs administered by a physician or clinic, 6
       and 8N, 6                                                       enteral nutrition product non-benefit exceptions, 5
      ineligible children, 4                                           Hepatitis-B vaccine, 2
      Medicare/Medi-Cal crossovers, 4                                  incontinence supplies, 1
      non-covered services, 6                                          newborn infant using mother's ID number, 5
   185 and 200 Percent Programs                                        presumptive eligibility cards, 6
      185 Percent Program, 1                                           restricted eligibility, 6
      200 Percent Program, 1                                           special project enrollees, 6
      aid codes, 2                                                     submitting copies of TARs, 1
      billing newborn on mother's ID, 2                             Pharmacy Claim Form (30-1) Submission and
      coverage, 1                                                    Timeliness Instructions, P2: PH pcf30-1 sub
      dual eligibility and Share of Cost, 2                            claims over one year old, 2–5
      emergency services for infants with aid codes 69 and             late billing instructions, 2
       07, 3                                                           six-month billing limit, 1
      infant: continuous inpatient care beyond first                   where to submit claims, 1
       birthday, 2
      Medicare/Medi-Cal crossovers, 1
      pregnancy-related services, 3
Percent Programs, P1: percent (continued)
   Continued Eligibility Program
      aid codes, 9
      coverage for infants, 9
      coverage for pregnant women, 8–9
      families with a share of cost, 10
      infant's card, 10




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
58 Section Titles/Headings Index
Pharmacy Claim Form (30-1) Tips, P2: PH pcf30-1 tips                Physician-Adminstered Drugs – NDC:
   common attachment reminders, 3                                   UB-04 Billing Instructions P2: GM OB
   common billing errors, 1–2                                        ADU AIDS DIA CAH EAP HER HOM HGOS
   field completion reminders, 4                                     MSSP REH, physician ndc ub, 1–2
   paper claim form requirements, 5                                 PIA Optical Laboratories, P2: VC pia
Physical Therapy, P2: ADU REH THP phys                                 Laboratory Services
   claim information, 4                                                    contract laboratories, 1
   eligibility requirements, 1                                             delivery services, 4
   prescription requirements, 1–2                                          frames, 2
   prior authorization, 3                                                  glass lenses, 3
   program coverage, 1                                                     lens styles, 2
   speech generating devices (SGD), 3–4                                    miscellaneous lens items, 3
   where to submit TARs, 3–4                                               non-PIA contracted benefits, 4
Physical Therapy: Billing Codes and Reimbursement                          polycarbonate lenses, 2
 Rates, P2: ADU REH THP phys cd                                            processing period, 4
   codes and rates, 3–4                                                    replacements or repairs, 3
   definitions, 1–2                                                        tints and photochromatic lenses, 3
Physical Therapy Billing Example: CMS-1500,                            Recipient Eligibility
 P2: THP phys exc                                                          ineligibility, 1
   billing tips, 1                                                         managed care plans, 1
   physical therapy visits, 2–3                                            other health coverage, 2
Physical Therapy Billing Example: UB-04,                                   verification, 1
 P2: ADU REH phys exu                                               PIA Optical Laboratories: Code Directory,
   billing tips, 1                                                   P2: VC pia code dir
   physical therapy services, 2–3                                      contract laboratories, 1–3
Physician-Adminstered Drugs – NDC:                                  PIA Optical Laboratories: Order Form Completion,
 P2: GM OB ADU AIDS DIA CAH EAP                                      P2: VC pia frm comp
 HER HOM HGOS MSSP REH, physician ndc, 1–2                             explanation of form items, 3–5
Physician-Adminstered Drugs – NDC:                                     field completion reminders, 6
CMS- 1500 Billing Instructions P2: GM OB                               laboratory services, 1–2
 physician ndc cms, 1–2                                                ordering information, 1




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 59
Podiatry Services, P2: CAH GM podi                                  Preadmission Screening Resident Review (PASRR),
   benefit limitations (CCR, Section 51304), 1                       P2: IP LTC preadmis
   "by report" requirements, 7                                         Medi-Cal NF Resident Exempt From PASRR
   covered services (CCR, Section 51310), 1                                change in health status, 8–9
   definition of emergency services                                        ICF/DD and state developmental centers, 8
    (CCR, Section 51056), 2                                                less than 30-day exempt, 7
   immediate or emergency services, 2                                      swing beds, 8
   Medi-Services and TAR requirements, 3–6                             Mental Illness
   reimbursement for podiatry services (CCR, Title 22,                     "triggers", 24–25
    Section 51505.1), 2                                                Mental Retardation
Podiatry Services Billing Examples: CMS-1500,                              developmental disability: state definition, 27
 P2: GM podi cms                                                           mental retardation: federal definition, 28
   surgical procedure and supplies, 2–3                                    "triggers", 26–27
Podiatry Services Billing Example: UB-04,                              Part 1: Responsibility for Performing PASRR Level I
 P2: CAH podi ub (continued)                                            Screenings
   billing tips, 1                                                         delegated acute hospital, 2
   surgical procedure by podiatrist and supplies billed by                 introduction, 2
    surgery clinic, 2–4                                                    nondelegated acute hospital, 3
Point of Service (POS), P1: point                                          nursing facility, 4
   installation manual and POS Device User Guide, 1                    Part 2: Medi-Cal Recipients Subject to PASRR
   interface specifications, 1                                             continuing NF resident, 6
   ordering, 1                                                             interfacility transfer, 7
   performing Family PACT transactions, 2                                  introduction, 5
   queries, 2                                                              level I and level II new admission, 5
                                                                           MI/MR NF resident subject to resident review, 6
                                                                           out of NF system more than 90 days, 5
                                                                           readmission, 7
                                                                           retroactive eligibility for Medi-Cal, 5
                                                                       Part 3: Description of PASRR Process
                                                                           PASRR level I, 10–11
                                                                           PASRR level II, 11–14




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
60 Section Titles/Headings Index
Preadmission Screening Resident Review (PASRR),                     Pregnancy: Comprehensive Perinatal Services Program
 P2: IP LTC preadmis (continued)                                     (CPSP), P2: CAH MS preg com (continued)
   Part 4: PASRR and TAR Processing                                    Reimbursable Services
       30-day exempt, 15                                                   billing combined assessments, 5
       level I/level II documentation, 20                                  billing individual assessments, 6
       Medi-Cal field office review, 20                                    breast-feeding-related services, 6
       new admission, 15                                                   CPSP and obstetrical out-of-clinic services, 4
       reauthorization after level II, 18                                  date of entry into care, 5
       reauthorization when change of status, 18–19                        eligible in-home services providers, 7
       referral, 15                                                        hospital reimbursement: outpatient providers, 8
       resident review documentation, 20                                   intervention services, 6
       retroactive eligibility, 15                                         preventive in-home services, 7
       TAR completion procedures: initial authorization, 17                sequence of services, 6
       TAR submission: initial authorization, 16                           services reimbursable to CPSP providers only, 3
   Part 5: Completion of PASRR DHS 6170                                    traditional maternity services, 4
       introduction, 21–23                                             Share of Cost
   Preadmission Screening (PAS)                                            requirements, 12
       introduction, 1                                                 Special Reimbursement Bonuses
       preadmission screening resident review (PASRR), 1                   basic services, 11
Pregnancy: Comprehensive Perinatal Services Program                        support services, 11
 (CPSP), P2: CAH MS preg com                                           Treatment Authorization Requests
   Billing Instructions                                                    additional CPSP services, 12
       calculating billing units, 13                                Pregnancy: Comprehensive Perinatal Services Program
       introduction, 13                                              (CPSP) Billing Examples–CMS-1500,
   Incentives for Early and Frequent Prenatal Care                   P2: MS preg com exc
       billing 10th antepartum visit: HCPCS code Z1036, 10             antepartum nutrition psychosocial and health assessment
       billing initial office visit: early entry rendered by            services, 3
         NMP, 9                                                        billing tips, 1
       billing initial office visit: modifier -ZL, 9                   breastfeeding, 3–4
       introduction, 9                                                 combined assessments and initial office visit within four
       modifier tips, 9                                                 weeks, 2
   Policies and Reimbursement                                          early and frequent prenatal care, 5
       introduction, 2                                                 TAR and claim for reimbursement of excess
   Provider Participation                                              services, 7–9
       applying to become a CPSP provider, 1                           tenth antepartum office visit, 6
       eligible providers, 1
       list of contract service providers,2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
                                                                          Section Titles/Headings Index 61
Pregnancy: Comprehensive Perinatal Services Program                 Pregnancy: Early Care and Diagnostic Services,
 (CPSP) Billing Examples–UB–04,                                      P2: CAH MS preg early
 P2: CAH preg com exu                                                  cordocentesis, 11
   antepartum nutrition, psychosocial and health assessment            comprehensive perinatal services program, 2
     services, 15                                                      delalutin for history of previous pre-term labor, 4
   billing nutritional services and health education                   duplex scan of arterial/venous flow, 11
     services, 5–6                                                     fetal fibronectin testing, 11
   billing tips, 1                                                     fetal stress, non-stress testing, 12
   breastfeeding, 15–17                                                genetic testing, 4
   combined assessments and initial office visit within four           glucometers for gestational diabetics, 4
     weeks, 2–4                                                        non-pregnancy related office visit, 3
   perinatal education in a group environment, 7–8                     obstetric panel frequency restriction, 11
   TAR and claim for additional CPSP support                           pregnancy-related office visit, 3
     services, 11–14                                                   prenatal care guidance program, 1–2
   tenth antepartum visit, 9–10                                        presumptive eligibility program, 1
Pregnancy: Comprehensive Perinatal Services Program                    preventing preterm births: 17a-hydroxyprogesterone
 (CPSP) List of Billing Codes, P2: CAH MS preg com lis                   injections, 4
   comprehensive health education services, 3–4                        ultrasound during pregnancy, 4–7
   comprehensive psychosocial services, 2                              urinalysis (routine), 3
   initial comprehensive services, 1                                Pregnancy Examples: CMS-1500, P2: MS preg ex cms
   nutrition services, 1–2                                             global billing of C-section with tubal ligation, 11–13
   office visits, 1                                                    internal fetal monitor billed with modifier –99, 10
Pregnancy: Comprehensive Perinatal Services Program                    multiple births: claims for twins A and B using mom's
 (CPSP)–Los Angeles County Waiver Facilities,                           Medi-Cal ID number, 4–7
 P2: CAH preg com los                                                  per-visit billing of antepartum office visit and
   reimbursable codes, 1–3                                              ultrasound, 9
Pregnancy Determination, P2: CAH preg determ                           per-visit billing of C-section and postpartum
   initial office visit, 1                                              office visit, 8
   pregnancy testing, 1                                                per-visit billing of vaginal delivery and antepartum office
   pregnancy verification signature, 1                                  visit, 2–3
                                                                       preventing preterm births: 17a-hydroxyprogesterone
                                                                         injections, 14–16
                                                                    Pregnancy Examples: UB-04, P2: CAH preg ex ub
                                                                       billing tips, 1
                                                                       fetal stress testing, 8
                                                                       per-visit billing of antepartum office visit, ultrasound
                                                                        and amniocentesis, 7–9
                                                                       per-visit billing of initial antepartum visit and antepartum
                                                                        office visit, 2–4
                                                                       per-visit billing of new patient office visit, pregnancy
                                                                        test and initial antepartum visit on same date of
                                                                        service, 12–16
                                                                       per-visit billing of postpartum office visit, 5–6




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services     OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                        LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program         MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals       REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                        PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                    VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                     July 2011
62 Section Titles/Headings Index
Pregnancy: Fetal Monitoring, Labor and Delivery                     Prescription Referrals, P2: CAH GM prescript
 Services, P2: CAH MS preg fetal                                       blood glucose monitors, 8–9
   assistant surgeon services, 3                                       elastic stockings, 7
   external/internal fetal monitoring during labor, 1–2                foot inserts/arch supports, 5–6
   physician on call for C-section or complicated delivery, 3          prescription requirements for certified optometrists, 1
   spontaneous abortion, 3                                             prescription requirements for DME rentals and
Pregnancy: Global Billing, P2: CAH MS preg glo                          purchases, 7
   global billing, 1–3                                                 prescription requirements for orthotic and prosthetic
   Other Health Coverage requirements, 3                                appliances, 4-5
Pregnancy: Global Billing Codes,                                       prescription requirements for speech therapy, physical
 P2: CAH MS preg glo cd                                                 therapy, occupational therapy and audiology, 1–3
   global obstetrical codes, 1                                      Prescription Referrals: Vision Care, P2: VC prescript vc
Pregnancy: Per-Visit Billing, P2: CAH MS preg per                      certified optometrists, 1–2
   Other Health Coverage requirements, 2                            Presumptive Eligibility, P2: CAH MS PH presum
   per-visit billing, 1–2                                              AFDC applicants need not complete PREMED2, 16
Pregnancy: Per-Visit Billing Codes,                                    applying for participation and ordering forms, 22
 P2: CAH MS preg per cd                                                billing requirements, 22
   per-visit obstetrical codes, 1                                      code list of PE benefits, 17–20
Pregnancy: Postpartum and Newborn Referral Services,                   eligibility criteria, 1–5
 P2: CAH HOM IP MS preg post                                           eligibility limitations, 8
   breast feeding: services covered by Medi-Cal, 5                     income screening guidelines, 5–7
   early discharge, 1–3                                                Medi-Cal application package, 11–12
   newborn referral form, 6                                            Newborn Referral Form for PE providers, 22
   postpartum care for recipients who might otherwise be               non-benefits, 21
    ineligible: aid code 76, 3–5                                       PE card issuance, 9–10
Pregnancy: Share of Cost, P2: CAH MS preg share                        pregnancy test, 7
   Share of Cost guidelines for obstetrical services, 1                PREMED forms package, 11
                                                                       record retention, 12–15
                                                                       reporting PE, 12
                                                                       Professional Services, P2: VC pro serv




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 63
Professional Services, P2: VC pro serv                              Professional Services Billing Examples: CMS-1500,
   Billing                                                           P2: VC pro serv ex
       computerized corneal topography, 14–19                          billing tips, 1
       consultations, 8                                                interim comprehensive eye examination, 2–3
       contact lenses services, 8                                      ophthalmoscopy, extended, with retinal drawing, 6–7
       eye appliances, 7                                               out-of-office call, 4–5
       general ophthalmological services, 8                            visual field examinations, 6–7
       medical justification, 11                                    Professional Services: Diagnosis Codes,
       modifiers, 9–10                                               P2: VC pro serv cd, 1–5
       ocular prosthesis, 8                                         Programs Overview, P1: prog
       out-of-office calls, 9                                          Adult Day Health Care (ADHC) Centers, 1
       prescription for ophthalmic eyewear form                        AIDS Waiver Program, 1–2
         (DHS 6086) for dispensing providers, 20                       Breast and Cervical Cancer Treatment Program
       specific docmentation requirements, 12–14                        (BCCTP), 2
       unilateral and bilateral, 19                                    California Alternative Assistance Program (CAAP), 3
   Comprehensive Eye Examinations                                      California Children’s Services (CCS), 3
       determination of refractive state, 2                            Cancer Detection Programs: Every Woman Counts, 4
       diagnostic drugs, 2                                             Child Health and Disability Prevention
       E & M codes not reimbursable with eye                            (CHDP) program, 4
         examination services, 3                                       Comprehensive Perinatal Services Program (CPSP), 5
       interim examinations, 3                                         County Medical Services Program (CMSP), 6
       routine examinations, 2                                         Denti-Cal, 6
       tonometry, 2                                                    Drug Use Review (DUR), 6
   General Information                                                 Emergency Assistance (EA) Program, 7
       claim submission, 1                                             Expanded Access to Primary Care (EAPC), 7
       non-covered services, 2                                         Family PACT, 8
       program coverage, 1                                             Genetically Handicapped Persons Program (GHPP), 9
   Medicare/Medi-Cal Crossover Claims                                  Healthy Families, 9
       hard copy billing, 7                                            Heroin Detoxification, 10
       Medicare covered services, 7                                    Home and Community-Based Services (HCBS), 10
       Medicare non-covered, 7                                         Home Health Agencies, 10
   Supplemental Services                                               Hospice Care, 11
       covered services, 3–4                                           Indian Health Services Memorandum of Agreement
       definition, 3                                                    (IHS/MOA), 11
       teleophthalmology by optometrists, 4–6                          In-Home Medical Care (IHMC) Waiver program, 11
                                                                       Local Educational Agency (LEA), 12
                                                                       Managed Care information, 17
                                                                       Medical Case Management Program, 12




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
64 Section Titles/Headings Index
Programs Overview, P1: (continued)                                  Provider Guidelines, P1: prov guide
   Minor Consent program, 12                                           Change of Pay-To and/or Mailing Address
   Model-NF Waiver program, 13                                            address change forms for providers, 3–4
   Multipurpose Senior Services Program (MSSP), 13                        address change notice for non-providers, 4
   Nursing Facility (NF) Waiver program, 13                               where to submit address/status changes, 4
   OBRA and IRCA, 13                                                   DHCS and Provider Tax Reporting Responsibilities
   Prenatal Care Guidance program, 14                                     common TIN errors, 13–14
   Presumptive Eligibility (PE), 14                                       Form W-9, 12
   Rehabilitation clinics, 14                                             introduction, 12
   Rural Health Clinics (RHCs) and Federally Qualified                    IRS contacts, 14
    Health Centers (FQHCs), 15                                         Electronic Claim Submission
   Rural Hospital Swing Bed Program, 16                                   applications/agreement forms, 11
   Special group information, 17                                          introduction, 11
   Specialty Mental Health Services, 16                                Enrolling Hardcopy Billing Intermediaries
   Subacute Care programs, 17                                             billing intermediary registration numbers, 10
   Tuberculosis Program, 17                                               introduction, 9
   Vaccines For Children (VFC), 17                                        instructions for CMC submitters who also bill
Prosthetic Eyes, P2: VC prosth                                              hardcopy, 10
   documentation requirements for TARs/SARs, 2–3                          instructions to providers who use hardcopy billing
   modifiers, 3                                                             intermediaries, 10
   program coverage, 1                                                    where to submit notification and application
Provider Billing after Beneficiary Reimbursement                             forms, 10
 (Conlan v. Shewry), P2: AH IP LTC MS OP PH VC,                        Enrollment Information
 prov bil                                                                 enrollment applications, 6–7
   Appeal Process Overview                                                Medi-Cal supplemental application, 5–6
       Claims Inquiry Forms (CIFs), 3                                     overview, 5
       filing an appeal, 3                                             Inactivated Providers
       timeliness: 90-day deadline, 3                                     exceptions, 14
       where to submit appeals, 3                                         inactivation benefits, 15
   background, 1                                                          inactivation for returned mail, 15
   beneficiary service center, 1                                          introduction, 14
   BSC responsibilities, 1                                                reactivation procedures, 15
   claims for Medi-Cal managed care beneficiaries, 4
   claim submission, 2
   provider notification of beneficiary request for
    reimbursement, 2
   provider responsibility, 2
   reimbursement, 4




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 65
Provider Guidelines, P1: prov guide (continued)                     Provider Relations Directory, P1: prov rel
   Obligations to Recipients                                           Additional Resources
       circumstances that exempt providers from rendering                  Cash Control Unit, 7
         services, 8                                                       General Services Distribution, 7
       eligibility verification obligates provider to render               Print and Distribution Center, 7
         services, 7-8                                                     Publications Unit, 7
       non-SOC payments must be refunded, 9                            Billing Assistance
       payments from recipients, 8                                         Correspondence Specialist Unit, 4
       provider billing after beneficiary reimbursement, 8                 Out-of-State Unit, 4
   Participation Requirements                                              Small Provider Billing Unit, 4
       introduction, 2                                                     Telephone Service Center (TSC), 2
   Provider Enrollment                                                 Claim Status Inquiries
       DHCS provider enrollment division, 1                                Provider Telecommunications Network (PTN), 6
       how to enroll, 1                                                Communicating with Medi-Cal
   Rendering Provider                                                      Medi-Cal directory, 8–9
       rendering provider billing by group or clinic, 9                Eligibility Verification and Medi-Reservation
   Terminating Participation                                            Transaction Assistance
       voluntary provider termination, 15                                  Point of Service/Internet, 6
Provider Guidelines: Billing Compliance,                               Training Assistance
 P1: prov guide bil                                                        Provider Training Unit, 5
   falsifying information, 1                                               Regional Representatives, 5
   medi-cal provider fraud and abuse, 1
   procedure/drug code limitation, 2
   special claims review, 1
   Suspended and Ineligible List
       investigations offices, 4
       recipient fraud, 3
       suspended and ineligible provider list, 3
       suspension by DHCS, 3
Provider Regulations, P1: prov reg
   civil money penalties, 3–4
   computer claims submission violators, 3
   confidentiality, 1
   continuance policy for administrative hearings on
     provider overpayments, 4–7
   copayment criteria, 8–9
   discriminatory billing for third party liability, 13
   liens, 13–14
   patient self-determination of medical treatment:
     OBRA 1990, 17–18
   recipient liability, 14
   record keeping criteria, 1–3
   retroactive eligibility: provider obligations, 15–16
   third party liability and copayments, 10–12



PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
66 Section Titles/Headings Index
Provider Telecommunications Network (PTN),                          Psychiatry, P2: CAH GM psych
 P1: prov tele                                                         Clozaril (clozapine) therapy, 4
   General Information                                                 diagnosis codes, 1
       hours of operation, 2                                           Evaluation & Management (E & M) services, 4–5
       Provider Identification Number, 2                               group medical psychotherapy, 2
       PTN access, 1                                                   hypnotherapy, 3
       touch-tone-telephone required, 2                                non-covered mental health services, 4
   Operational Information                                             nursing facility resident authorization requirements
       accelerated access, 8                                             (Valdivia v. Coye), 7–12
       alphabetic code listing, 8                                      pharmacologic management: not separately
       error limit, 7                                                    reimbursable, 5
       repeating PTN information, 8                                    psychiatric services for hospital and nursing facility
       time limit between prompts, 7                                     inpatients, 5–6
   PTN Categories                                                      psychotherapy, 1
       appeal status inquiry, 6                                        utilization controls on outpatient psychiatric
       claims status inquiry, 4                                          services, 2–3
       continuing care inquiry, 4–6                                 Psychological Services, P2: PSY psycho
       general information inquiry, 6                                  authorization, 2
       information available from the PTN, 3                           case conference, 5
       procedure, national drug or medical supply code                 eligibility requirements, 1–2
         pricing inquiry, 6                                            family therapy, 2
       provider checkwrite, 3                                          group therapy, 2
       Treatment Authorization Request status inquiry, 4               ICD-9-CM codes, 4
   Step-By-Step Instructions and Messages                              individual therapy, 3
       appeal status inquiry: selection 6, 25                          Medicare/Medi-Cal crossovers, 5
       claim status inquiry menu: selection 2, 12–15                   mental retardation diagnosis, 3
       completing the inquiry, 26                                      out-of-office call, 3
       continuing care inquiry: selection 4, 21–23                     place of service code "99", 3
       general information inquiry: selection 7, 26                    program coverage, 1
       procedure, national drug or medical supply code                 psychodiagnostic testing, 4–5
         inquiry: selection 5, 24                                      test administration time, 4
       provider checkwrite menu: selection 1, 10–11                 Psychological Services: Billing Codes and
       step 1: initiate the call, 9                                  Reimbursement Rates, P2: PSY psycho cd
       step 2: enter PIN, 9                                            codes and rates, 1–3
       step 3: provider selection menu, 9                           Psychology Services: Billing Examples,
       TAR status inquiry: selection 3, 16–20                        P2: PSY psycho ex
                                                                       billing tips, 1
                                                                       multiple therapy sessions, 2–3
                                                                       psychological testing, 4–5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services     OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                        LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program         MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals       REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                        PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                    VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
                                                                          Section Titles/Headings Index 67
R                                                                   Radiology: Diagnostic, P2: CAH MS radi dia
Radiology, P2: CAH MS radi                                             (continued)
   billing method guidelines, 1–2                                      low/high osmolar radiographic contrast media
   CLIA number: billing for radiology, 3                                guidelines, 8
   CPT-4 codes , not split billable, 8                                 Magnetic Resonance Cholangiopancreatography
   diagnosis code requirement, 1                                        (MRCP), 6
   injection not separately reimbursable, 9                            Magnetic Resonance Imaging and
   imaging procedure, 8                                                  Magnetic Resonance Angiography, 3–4
   invoice requirements for “no price on file” items, 2                miscellaneous, 17
   magnetic resonance imaging & magnetic resonance                     national correct coding initiative impact, 1
     angiography, 9                                                    organized outpatient clinics, 4
   reimbursement restrictions, 5–7                                     paramagnetic contrast material, 7
   rendering provider number, 3                                        placement of distal extension prosthesis, 17
   ultrasound frequency limitations, 10                                placement of proximal extension prosthesis, 17
   unlisted services, 4                                                portable X-ray transportation, 11
Radiology Billing Example: CMS-1500,                                   radiopharmaceutical contrast materials, 8
 P2: MS radi bil cms                                                   screening mammography, 14
   bilateral radiology billed with unilateral codes, 4–5            Radiology: Diagnostic Ultrasound,
   chest X-ray, 2–3                                                  P2: CAH MS radi dia ult
Radiology Billing Example: UB-04,                                      codes billed with modifier 26, 2
 P2: CAH radi bil ub                                                   codes not split-billable, 3
   bilateral radiology billed with unilateral codes, 4–5               ultrasound: head and neck, 2
   billing tips, 1                                                     ultrasound of infant hips, 1
   chest X-ray, 2–3                                                    ultrasound of the breast, 1
Radiology: Diagnostic, P2: CAH MS radi dia                             ultrasound of the sinuses, 1
   angiographic procedures by serialography, 16                        ultrasound: pelvic, non-obstetric, 1
   angiography for areteriovenous shunt imaging, 17                    ultrasound: spinal canal, 2
   chest X-rays, 9–10                                               Radiology: Nuclear Medicine, P2: CAH MS radi nuc
   computerized tomography scan guidelines, 1–3                        positron emission tomography (PET) scan, 1–3
   contrast media, 7                                                   single photon emission computed tomography
   diagnostic mammography, 14                                            (SPECT), 1
   dual energy X-ray absorptiometry (DXA), 15
   echocardiography contrast agents, 8–9
   fluoroscopy and esophagus studies, 12
   implantable tissue marker, 17
   intravenous radiopharmaceutical therapy, 17




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
68 Section Titles/Headings Index
Radiology: Oncology, P2: CAH MS radi onc                            Rates: Maximum Reimbursement,
   clinical brachytherapy radioactive materials, 4                   P2: CAH MS rates max
   consultation: clinical management, 1                                anesthesia: Certified Registered Nurse Anesthetist
   CPT-4 code 77427 radiation treatment management, 5                   (CRNA), 1
   ibritumomab Tiuxetan (Zevalin), 7-8                                 anesthesia supervision, 2
   local hyperthermia cancer treatment, 6                              anesthesia physician, 1
   outpatient visits and radiation or                                  individual laboratory tests, 7
      radiopharmaceutical therapy, 1                                   newborn screening, 7
   provision of unlisted radiopharmaceutical(s), 5                     other services and supplies, 8
   radiation oncology and radiopharmaceutical                          pathology, 6
      therapy, 1                                                       physician services chart: unit value conversion
   radiation treatment codes not split-billable, 1–4                    factors, 2–5
   samarium SM-153 HCPCS code A9604, 5                                 podiatry, 6
   tositumomab, 9                                                      reimbursement calculation for physician services, 1
   vaginal cylinder HCPCS code S2270, 5                             Rates: Maximum Reimbursement for Dispensing and
Rates: Facilities, P2: LTC rate facil                                Repair Fees, P2: VC rates max disp
   AB 360 (2005), 7                                                    codes and rates, 1
   developmentally disabled oversight program add-on, 2             Rates: Maximum Reimbursement for Eye Appliances,
   ICF/DD-continuous nursing, 4                                      P2: VC rates max eye app
   ICF/DD regulations, 3–4                                             codes and rates, 3–9
   included costs, 1–2                                                 “diopter” defined, 1
   new facilities: statewide average rate, 5–7                         eyeglass lens dispensing fees, 1
Rates: Facilities, P2: LTC rate facil (continued)                      spectacle lens codes, 1–2
   out of state providers, 7                                        Rates: Maximum Reimbursement for Laboratories,
   per-diem add-on, 2                                                P2: CAH MS rates max lab 1–8
   Valdivia v. DHS and CAHF v. DHS, 5                               Rates: Maximum Reimbursement for Optometry
Rates: Facility Per Diem, P2: LTC rate facil diem, 1–7               Services, P2: VC rates max optom, 1–5
Rates: Facility Reimbursement–Miscellaneous Inclusive               Rates: Maximum Reimbursement for Outpatient Room
 and Exclusive Items, P2: LTC rate facil misc                        Rates, P2: CAH rates max op
   exclusive items, 3–5                                                hospital outpatient departments and organized outpatient
   inclusive items, 1–2                                                 surgical facilities, 1
   transfer of assets rule: restricted services message
     "RES LTC", 6




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
                                                                          Section Titles/Headings Index 69
Rehabilitative Services, P2: REH rehab                              Reject Codes for the Medi-Cal-Supplied POS Device and
   billing for preliminary evaluation, 1–2                           Real-Time Internet Pharmacy (RTIP),
   facility type/place of service codes, 4                           P2: PH reject cd pos, 1–11
   prior authorization: extended treatment                          Remittance Advice Details (RAD), P2: remit adv
    plan required, 3                                                   accounts receivable transactions, 4
Reimbursement, P2: PH reimbursement                                    adjustments, 1
   Dispensing Quantity Limitations                                     approves, 2
       100 calendar day supply, 10                                     denies, 2–3
   Reimbursement Guidelines                                            no payment advice, 4
       after hours and delivery services, 9                            suspends, 3
       average wholesale price (AWP), 3                             Remittance Advice Details (RAD) and Medi-Cal
       compounded prescriptions, 3                                   Financial Summary, P1: remit
       disposable intravenous pumps, 7                                 accounts receivable transactions, 3
       drugs provided to physicians, hospital emergency                adjustments, 2
         rooms, outpatient clinics, or nursing facilities for          approves, 2
         dispensing or administering, 6                                denies, 2
       enteral nutrition products, 1                                   explanation of form items, 5–6
       estimated acquisition cost (EAC), 3                             glossary, 7
       federal upper limit (FUL), 5                                    Medi-Cal Financial Summary, 4
       home infusion preparation, 8                                    suspends, 3
       legend drugs, 1                                              Remittance Advice Details (RAD) and Reconciling
       MAIC price changes, 5                                         Medi-Cal Payment, P1: remit and
       maximum allowable ingredient cost (MAIC), 4                     misdirected RADs and warrants, 2
       non-legend over-the-counter (OTC) drugs, 1                      missing warrants, 1
       pharmacy discounts, 9                                           retaining RADs, 2
       sales tax, 3                                                    returned warrants, 1
   Reimbursement Limitations
       code 1 limitations, 11
       continuing care 14
       items not covered, 13-14
       six drug claim lines per patient per month, 11-12
       three in 75-day billing, 13




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
70 Section Titles/Headings Index
Remittance Advice Details (RAD) Codes and Messages:                 Remittance Advice Details (RAD) Electronic Correlation
 001-099, P1: remit cd001, 1–18                                      Tables to National Codes:
Remittance Advice Details (RAD) Codes and Messages:                  200-299, P1: remit elect corr200, 1–15
 100-199, P1: remit cd100, 1–14                                     Remittance Advice Details (RAD) Electronic Correlation
Remittance Advice Details (RAD) Codes and Messages:                  Tables to National Codes:
 200-299, P1: remit cd200, 1–11                                      300-399, P1: remit elect corr300, 1–16
Remittance Advice Details (RAD) Codes and Messages:                 Remittance Advice Details (RAD) Electronic Correlation
 300-399, P1: remit cd300, 1–12                                       Tables to National Codes:
Remittance Advice Details (RAD) Codes and Messages:                  400-499, P1: remit elect corr400, 1–11
 400-499, P1: remit cd400, 1–10                                     Remittance Advice Details (RAD) Electronic Correlation
Remittance Advice Details (RAD) Codes and Messages:                  Tables to National Codes:
 500-599, P1: remit cd500, 1–8                                       500-599, P1: remit elect corr500, 1–12
Remittance Advice Details (RAD) Codes and Messages:                 Remittance Advice Details (RAD) Electronic Correlation
 600-699, P1: remit cd600, 1–11                                      Tables to National Codes:
Remittance Advice Details (RAD) Codes and Messages:                  600-699, P1: remit elect corr600, 1–14
 700-799, P1: remit cd700, 1–9                                      Remittance Advice Details (RAD) Electronic Correlation
Remittance Advice Details (RAD) Codes and Messages:                  Tables to National Codes:
 800-899, P1: remit cd800, 1                                         700-799, P1: remit elect corr700, 1–4
Remittance Advice Details (RAD) Codes and Messages:                 Remittance Advice Details (RAD) Electronic Correlation
 900-999, P1: remit cd900, 1                                         Tables to National Codes:
Remittance Advice Details (RAD) Codes and Messages:                  800-899, P1: remit elect corr800, 1
 9000-9999, P1: remit cd9000, 1–45                                  Remittance Advice Details (RAD) Electronic Correlation
Remittance Advice Details (RAD): Electronic,                         Tables to National Codes:
 P1: remit elect                                                     900-999, P1: remit elect corr900, 1
   ANSI ASC x12N 835 transaction, 4                                 Remittance Advice Details (RAD) Electronic Correlation
   automated remittance data services, 1–3                           Tables to National Codes:
Remittance Advice Details (RAD) Electronic Correlation               9001-9099, P1: remit elect corr9000, 1–19
 Tables to National Codes:                                          Remittance Advice Details (RAD) Electronic Correlation
 011-099, P1: remit elect corr001, 1–14                              Tables to National Codes:
Remittance Advice Details (RAD) Electronic Correlation               9100-9199, P1: remit elect corr9100, 1–16
 Tables to National Codes:                                          Remittance Advice Details (RAD) Electronic Correlation
 100-199, P1: remit elect corr100, 1–13                              Tables to National Codes:
                                                                     9201-9299, P1: remit elect corr9200, 1–6
                                                                    Remittance Advice Details (RAD) Electronic Correlation
                                                                     Tables to National Codes:
                                                                     9500-9599, P1: remit elect corr9500, 1–12
                                                                    Remittance Advice Details (RAD) Electronic Correlation
                                                                     Tables to National Codes:
                                                                     9600-9699, P1: remit elect corr9600, 1–10




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 71
Remittance Advice Details (RAD) Electronic Correlation              Remittance Advice Details (RAD) Examples:
 Tables to National Codes:                                           Pharmacy, P2: PH remit ex ph
 9700-9799, P1: remit elect corr9700, 1–19                             crossover payments, 5
Remittance Advice Details (RAD) Electronic Correlation                 explanation of items, 2–7
 Tables to National Codes:                                          Remittance Advice Details (RAD) Examples: Vision
 9800-9899, P1: remit elect corr9800, 1–18                           Care, P2: VC remit ex vc
Remittance Advice Details (RAD) Electronic Correlation                 claim status, 7–8
Tables to National Codes:                                              crossover payments, 6
9900-9999, P1: remit elect corr9900 1–3                                explanation of form items, 3–6
Remittance Advice Details (RAD) Electronic Correlation              Remittance Advice Details (RAD): Payments and
 Tables to National Codes:                                           Claim Status, P2: remit pay
 HCRC to RAD, P1: remit elect corr hcrc, 1–4                           no record of claim, 3
Remittance Advice Details (RAD) Examples:                              overpayments, 1–2
 Allied Health and Medical Services,                                   reconsideration of denied claims, 3
 P2: AH MS remit ex am                                                 suspended claims, 3
   claim status, 6–7                                                   underpayments, 3
   crossover payments, 5                                            Respiratory Care, P2: DME REH THP respir
   explanation of form items, 2–5                                      definition of respiratory care services, 1–2
Remittance Advice Details (RAD) Examples:                              incentive spirometry, 7
 Inpatient Services, P2: IP remit ex ip                                injection codes, 6
   claim status, 7–8                                                   program coverage, 3–4
   crossover payments, 6                                               respiratory care practitioner services, 5
   explanation of form items, 3–5                                      respiratory care services, 1–2
Remittance Advice Details (RAD) Examples: Long Term                    ventilator management services, 8
 Care, P2: LTC remit ex ltc                                         Resubmission Turnaround Document (RTD)
   claim status, 7–8                                                 Completion, P2: resub comp
   crossover payments, 6                                               completing the RTD, 5
   explanation of form items, 3–5                                      explanation of form items, 1–4
Remittance Advice Details (RAD) Examples:                              timeliness, 5
 Outpatient Services, P2: OP remit ex op                               where to submit RTDs, 5
   claim status, 7–8                                                Resubmission Turnaround Document (RTD) Overview,
   crossover payments, 6                                             P1: resub
   explanation of form items, 3–6                                      timeliness, 2
                                                                       where to submit RTDs, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
72 Section Titles/Headings Index
Revenue Codes for Inpatient Services,                               Rural Health Clinics (RHCs) and Federally Qualified
 P2: IP rev cd ip                                                    Health Centers (FQHCs): Billing Codes,
   revenue code rates, 1                                             P2: ADU CAH rural cd
   revenue codes, 3–4                                                  RHC and FQHC: all inclusive per visit codes, 1–2
   billing administrative days: accommodation code 169, 2              RHC and FQHC: services for recipients in managed
   contract hospital reporting requirements, 2                           care and capitated Medicare Advantage plans
   contract hospitals: discharge codes, 2                                managed care plan, 4-5
   non-contract hospital reporting requirements, 1                     RHC and FQHC: services not covered by recipient's
   OSHPD accommodation code correlation table                           managed care plan, 3
    (for accounting purposes only), 1, 7–10                         Rural Health Clinics (RHCs) and Federally Qualified
   psychiatric services: authorization and reimbursement, 2          Health Centers (FQHCs) Billing Examples,
Rural Health Clinics (RHCs) and Federally Qualified                  P2: ADU CAH rural ex
 Health Centers (FQHCs), P2: ADU CAH IP rural                          billing tips, 1
   ADHC visits, 5                                                      managed care differential rate, 2–3
   authorization and document requirements, 3                       Rural Hospital Swing Bed Program, P2: LTC rural hosp
   billing services for health care plan recipients, 6                 eligibility requirements, 1
   CHDP/EPSDT reporting requirements and billing                       enrollment, 2
    for CHDP patients, 8                                               reimbursement, 2
   CPSP practitioner defined, 2
   CPSP services: TAR and reporting requirements, 4
   Federally Qualified Health Centers, 1
   health care plan recipients, 3
   physician defined, 2
   reimbursement, 6-7
   RHC and FQHC: enrollment, 2
   RHC and FQHC: medi-services, 4
   RHC/FQHC covered services, 3
   Riverbend government benefits administrator, 6
   Rural Health Clinics, 1
   "visit" defined, 4




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 73
S                                                                   Share of Cost (SOC): 30-1 for Pharmacy, P2: PH share ph
Share of Cost (SOC), P1: share                                         billing multiple services rendered on different dates of
   billing SOC, 12                                                      service, 3-4
   certifying SOC, 3–5                                                 billing multiple services rendered on the same date of
   claims processing: Share of Cost review, 12                          service, 5-6
   CMSP: SOC policy applies, 11–12                                     over-the-counter drugs included in the facility’s per-diem
   county welfare department generally determines SOC                   rate, 7
    amount, 1                                                          SOC field on claim, 2
   EVC number, 5                                                    Share of Cost (SOC): CMS-1500 for Vision Care,
   how to find out if a recipient must pay an SOC, 1                 P2: VC share vc
   Hunt v. Kizer, 13–15                                                billing multiple services rendered on different dates of
   Long Term Care facilities: Johnson v. Rank, 15                       service, 2–3
   Medicare/Medi-Cal crossover claims: recipient                       billing multiple services rendered on the same date of
    liability, 12                                                       service, 4–5
   multiple aid codes and SOC, 6                                       SOC field on claim, 1
   multiple case numbers, 7–9                                       Share of Cost (SOC): CMS-1500, P2: AH MS share cms
   obligating payment, 2                                               billing multiple services rendered on different dates of
   Share of Cost Medi-Cal Provider Letter (MC 1054), 12                 service, 2–3
   Sneede v. Kizer, 10–11                                              billing multiple services rendered on the same date of
Share of Cost (SOC): 25-1 for Long Term Care,                           service, 4–6
 P2: LTC share ltc                                                     SOC fields on claim, 1
   billing for LTC resident: aid code 13, 4                         Share of Cost (SOC): UB-04 for Inpatient Services,
   billing with non-covered services on claim, 5–6                   P2: IP share ip
   determining how much to bill Medi-Cal, 3                            inpatient SOC transactions, 3–5
   determining how much to bill recipient, 2                           where to enter SOC on UB-04 claim form, 2
   explanation of form items, 11–12                                 Share of Cost (SOC): UB-04 for Outpatient Services,
   non-covered medical services defined: requirements of             P2: ADU AID CAH DIA HER HOM HOS LEA REH
    Johnson v. Rank, 3                                               share op
   over-the-counter drugs included in facility's per-diem              billing multiple services rendered on different dates of
    rate, 7                                                             service, 3–4
   share of cost clearance transactions, 2                             billing multiple services rendered on same date of
   SOC field on claim, 3                                                service, 5–7
   SOC record keeping: record of non-covered services                  SOC field on claim, 2
    (DHS 6114), 7–10




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
74 Section Titles/Headings Index
Sign Language Interpretation,                                       Speech Therapy: Billing Codes and Reimbursement
 P2: AH CAH LTC MS OP PH sign                                        Rates, P2: ADU AUD REH THP speech cd
    billing, 3                                                         codes and rates, 1–2
    interpreter services guidelines, 2                              Speech Therapy Billing Example: CMS-1500,
    provider guidelines, 1                                           P2: AUD THP speech exc
    reimbursable HCPCS codes , 3                                       billing tips, 1
    sign language interpreter overview, 1                              out of office visit, 2–3
Specialty Mental Health Services, P2: CAH GM PSY spec               Speech Therapy Billing Example: UB-04,
   billing Medi-Cal: fee-for-service, 6–7                            P2: ADU REH speech exu
   consolidation program implementation, 1                             billing tips, 1
   MHP authorization and contact information, 4                        speech therapy, 2-3
   MHP options, 4                                                   Sterilization, P2: CAH IP MS ster
   MHP responsibilities, 3–4                                           anesthesia time, 25
   recipient enrollment and eligibility, 1                             authorization, 21
   specialty mental health services criteria, 1–3                      codes requiring consent forms, 26
   TARs approved prior to consolidation, 5                             CMS-1500 example: bilateral procedure, 24
Specialty Mental Health Services: Eligible Counties,                   coverage conditions, 1–3
 P2: CAH GM PSY spec cnty                                              essure system, ESS305, 21–23
   MHP authorization and contact information, 1–10                     human reproductive sterilization defined, 1
Speech Generating Devices (SGD),                                       hysterosalpingogram, 21
     P2: AUD CAH DME OAP THP spe dev                                   ICD-9-CM codes identifying sterilization procedures, 27
   Speech Generating Device (SGD) Services                             informed consent process, 4–6
        bundled therapy services and recipient assessments, 5       Sterilization, P2: CAH IP MS ster (continued)
        occupational therapy assessment services, 6                    retroactive coverage, 25
        physical therapy assessment services, 6                        sterilization and supplies require consent forms, 26
   Speech Generating Devices (SGD)                                     sterilization Consent Form corrections, 14–15, 19
        definition, 1                                                  sterilization Consent Form instructions, 9–15
        purchases or rentals, 1                                        sterilization Consent Form (PM 330):
        Treatment Authorization Requests (TARs), 1                       general information, 7–8
Speech Therapy, P2: ADU AUD REH THP speech                             sterilization Consent Form signature, 16–18
   eligibility requirements, 1–2                                       sterilization services inquiries, 27
   initial and six-month evaluations, 4                                subtotal or total hysterectomy after cesarean delivery, 20
   prior authorization, 3–4                                            tubal ligations, 20
   program coverage, 1                                                 UB-04 example: bilateral procedure, 25
   required professional experience services:
     reimbursable, 5
   speech generating devices (SGD), 2
   written referral requirements, 2




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
                                                                          Section Titles/Headings Index 75
Subacute Care Programs: Adult,                                      Supplies and Drugs, P2: CAH MS supp drug
 P2: CAH GM LTC PH subacut adu                                         anesthesia-related drugs/supplies, 2–3
   administrative day, 2                                               drugs provided to physicians, hospital emergency rooms,
   eligibility criteria, 1                                               hospital satellite clinics or nursing homes, 1
   hours of licensed nursing required per patient day, 2               intravenous and irrigation solutions, 1
   manual of criteria, 4                                            Supplies and Drugs Billing Examples: UB-04,
   per diem rate, 3–4                                                P2: CAH supp drug bil
   treatment procedures, 1                                             billing tips, 1
Subacute Care Programs: Billing Codes,                                 emergency room supplies: HCPCS code Z7610, 2–4
 P2: CAH GM LTC subacut code                                        Supplies and Drugs for Medical Services,
   billing codes, 1–7                                                P2: MS supp drug ms
Subacute Care Programs: Level of Care for Adults and                   unlisted supplies and materials (CPT-4 code 99070), 1–2
 Children, P2: CAH GM LTC PH subacut lev                            Supplies and Drugs for Outpatient Services,
   billing procedures, 2–3                                           P2: CAH DIA REH supp drug op
   drugs listed and unlisted, 2                                        cataract surgery supplies, 3
   excluded items, 2                                                   miscellaneous drugs/supplies: HCPCS code Z7610, 1–2
   policies and reimbursement, 3–4                                     Naltrexone (injectable form), 4
   subacute care unit: program enrollment and inquiries, 4             Naltrexone (oral form), 4
   TAR requirements, 1                                                 supplies and materials (CPT-4 code 99070), 3
Subacute Care Programs: Pediatric,                                  Surgery, P2: CAH MS surg
 P2: CAH GM LTC PH subacut ped                                         billing for sling graft repair device, 3
   Eligibility and Services                                            duplicate billing with surgical modifiers, 5
       administrative day, 3                                           examination of tissue specimens: reimbursement
       eligibility criteria, 1                                           restrictions, 3-4
       hours of licensed nursing required per patient, 2               multiple surgeries: billing vascular injection
       occupational, physical and speech therapy services, 3             with cardiovascular procedure, 2
       per diem rate, 4                                                multiple surgeries: select procedures not payable for
       registered dietitian services, 3                                  same recipient, same date of service, 1–2
       respiratory therapy services, 3                                 prosthetic implant, 2
       treatment procedures, 1–2                                       pulse oximetry, 3
   Supplemental Rehabilitation Therapy Services and                    same day surgical admissions: guidelines and
   Ventilator Weaning Services                                           exceptions, 4
       introduction, 5                                                 scoliosis surgery and somatosensory tests, 4
       supplemental rehabilitation therapy services, 6–8               surgical centers, 5
       ventilator weaning services, 8–10                               surgical implantable device reimbursement, 5–6
                                                                       'unlisted' surgical CPT-4 codes require TAR, 2
                                                                       Voice Bak Prosthesis, 5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
76 Section Titles/Headings Index
Surgery: Auditory System, P2: CAH GM surg aud                       Surgery: Cardiovascular System,
   cochlear implantation, 1–2                                        P2: CAH GM surg cardio
   cochlear implant frequency restrictions, 4                          cardiac implantable devices and stents, 4–5
   cochlear implant minor repairs, replacement batteries and           complex venipunctures: age restrictions, 1
   accessories. 3                                                      coronary artery bypass, 2
Surgery Billing Examples: CMS-1500,                                    implantable infusion pump codes, 1
 P2: MS surg bil cms                                                   low-density lipoprotein-apheresis, 3
   destruction of 15 or more skin lesions, 11                          percutaneous transluminal coronary balloon
   destruction of five skin lesions, 10                                  angioplasty, 2
   modifier -50, 2–3                                                   placement of distal prosthesis, 1
   modifiers -80 and -99, 9–10                                         repair of pulmonary artery, 1
   multiple bilateral procedures modifiers -AG, -50, -51 and           second assistant surgeon, 5
     -99, 6–7                                                          selected coronary intervention procedures, 4–5
   modifier -AG, 4–5                                                   septal defect and venous anomalies, 2
Surgery Billing Examples: UB-04, P2: CAH surg bill ub                  ventricular assist devices, 5
   billing tips, 1                                                  Surgery: Digestive System, P2: CAH GM surg digest
   destruction of 15 or more skin lesions, 16–17                       frenoplasty, 1
   destruction of five skin lesions, 14–15                             frenotomy, 1
   modifier -50, 2–4                                                   morbid obesity: surgical treatment, 1–2
   modifiers -80 and -99, 11–13                                     Surgery: Eye and Ocular Adnexa, P2: CAH GM surg eye
   multiple bilateral procedures modifiers -AG, -50,                   bilateral cataract surgery, 3
     -51 and -99, 8–10                                                 blepharoplasty and/or repair for blepharoptosis, 7
   modifier -AG, 5–7                                                   cataract extraction surgery, 2
Surgery: Billing With Modifiers,                                       intra-ocular lens with cataract surgery, 4
 P2: CAH MS surg bil mod                                               keratoplasty, 9
   assistant at surgery: podiatrists, 8                                keratoprosthesis, 9
   assistant surgeons: modifiers -80 and -99, 8                        posterior capsulotomy, 4
   billing multiple modifiers, 5                                       retinal surgery: repetitive services, 1
   physician assistant: modifier -AS, 8                                retinal surgery: vitrectomy, 2
   separate operative sessions on same date of service, 1–2            supplies and drugs with cataract surgery, 4
   strabismus procedures: modifier -51 with
    CPT-4 code 67335, 4
   surgical procedures require modifiers, 1
   surgical team: modifier -66, 5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 77
Surgery: Female Genital System,                                     Surgery: Nervous System, P2: CAH GM surg nerv
 P2: CAH MS surg female                                                cervical laminectomy, 2
   cervical cauterization: assistant surgeon and                       deep brain stimulation, 3–7
     anesthesiology services not a benefit, 2                          nerve block injections, 1
   cervical conization: assistant surgeon services not a               percutaneous laminotomy/laminectomy, 1
     benefit, 2                                                        spinal neurostimulators, 2
   dilation and curettage, 2                                           stereotactic pallidotomy, 11–12
   prophylactic salpingo-oophorectomy, 1                               stereotactic radiosurgery, 11
Surgery: Integumentary System, P2: CAH GM surg integ                   Vagal Nerve Stimulator, 8–11
   bio-engineered skin substitutes, 4                               Surgery: Room Reimbursement, P2: CAH surg room
   destruction of benign or pre-malignant lesions, 3–4                 operating room reimbursement, 1
   epidermal autografts: "add-on" codes, 2                             recovery room reimbursement, 1
   microvascular free flaps: billing "by report" required, 2        Surgery: Urinary System, P2: CAH MS surg urin
   nail debridement, 2                                                 billing restrictions, 4
   port wine hemangiomas: argon laser treatments, 1                    endoscopic injections: urinary incontinence, 4
   skin debridement, 1                                                 cystourethroscopy: ureteral catheterization, 4
Surgery: Laparoscopy and Hysteroscopy,                                 Extracorporeal Shock Wave Lithotripsy, 1
 P2: CAH MS surg lap                                                   inflatable uretheral/bladder neck sphincter billing
   laparoscopy: assistant surgeon services reimbursable, 1               restrictions, 4
   laparoscopy codes, 1                                                injectable bulking agent, 3
Surgery: Male Genital System, P2: CAH MS surg male                     percutaneous nephrolithotomy, 3
   erectile dysfunction: diagnostic evaluation, 1                      prosthetic implant, 3
   frenulotomy of penis, 1                                             second assistant surgeon, 5
   penile prostheses, 1-2                                              transurethral needle ablation, 5
Surgery: Musculoskeletal System,                                       urethral dilation documentation requirements, 5
 P2: CAH GM surg muscu                                                 urodynamic studies: diagnosis and billing limitations, 2
   arthroscopy, 3–5                                                 Suspended and Ineligible Provider List (Medi-Cal),
   arthroscopy, knee, 3–4                                            P1: suspend
   bone graft harvesting, 2                                            * access on the Internet at www.medi-cal.ca.gov
   cast and splint materials, 5–6
   documentation required for multiple tendon/ligament
      injections, 7
   electrical stimulation to aid bone healing, 2
   idiopathic scoliosis: when to bill "by report", 1
   spinal instrumentation, 7




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP     All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA    LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS    MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH    Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH     All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC     All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                   July 2011
78 Section Titles/Headings Index
T                                                                   TAR Completion, P2: ADU AUD CAH DIA DME HER
TAR and Non-Benefit: Introduction to List,                           HOM HOS IP MS MTR OAP PH PSY REH THP tar comp
 P2: CAH IP MS tar and non                                             adjudication response (AR), 3
   ambulatory surgical (5), 2                                          BCCTP TARs, 2
   inpatient hospitalization stay: prior authorization                 DME and medical supplies, 2
    reminder, 2                                                        day of admission definition, 1
   non-benefit, 1                                                      drug authorizations, 2
   non-benefit, anesthesiologist (4), 1                                elective admissions, 1
   non-benefit, assistant surgeon (3), 1                               emergency admissions, 1
   requires TAR, primary surgeon/provider (2), 1                       explanation of form items, 5–12
TAR and Non-Benefit List: Codes 10000-19999,                           inpatient hospital stays, 1
 P2: CAH IP MS tar and non cd1, 1–4                                    local-to-HCPCS code conversion guidelines, 13–14
TAR and Non-Benefit List: Codes 20000-29999,                           multiple TARs, 3
 P2: CAH IP MS tar and non cd2, 1–7                                    negotiated prices, 3–4
TAR and Non-Benefit List: Codes 30000-39999,                           pharmacy TAR tips, 13
 P2: CAH IP MS tar and non cd3, 1–7                                 TAR Completion for Long Term Care,
TAR and Non-Benefit List: Codes 40000-49999,                         P2: LTC tar comp ltc
 P2: CAH IP MS tar and non cd4, 1–8                                    explanation of form items, 5–16
TAR and Non-Benefit List: Codes 50000-59999,                           glossary, 1–4
 P2: CAH IP MS tar and non cd5, 1–8                                 TAR Completion for Vision Care, P2: VC tar comp vc
TAR and Non-Benefit List: Codes 60000-69999,                           authorization procedures, 4–5
 P2: CAH IP MS tar and non cd6, 1–6                                    explanation of form items, 8–11
TAR and Non-Benefit List: Codes 70000-79999,                           first-level authorization request appeals, 6
 P2: CAH IP MS tar and non cd7, 1–3                                    modifiers, 3
TAR and Non-Benefit List: Codes 80000-89999,                           obtaining authorization, 1
 P2: CAH IP MS tar and non cd8, 1–2                                    second-level authorization request appeals, 6–7
TAR and Non-Benefit List: Codes 90000-99999,                           TAR request procedures, 2–3
 P2: CAH IP MS tar and non cd9, 1–8                                    where to submit prior authorization requests, 5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 79
TAR Criteria for DP/NF Authorization (Hudman v.                     TAR Discharge Planning Option,
 Kizer), P2: IP LTC tar crit dp                                      P2: ADU DIA DME HOM IP LTC MTR THP tar dis
   Forms                                                               Introduction
       Medi-Cal information sheet for hospital-based                       initiating discharge planning option, 1
        nursing facility patients, 7                                   Medi-Cal Managed Care Authorization Form (55-1)
       other forms, 7–10                                                   completing the Medi-Cal managed care authorization
   Key Definitions                                                          form (55-1), 4–5
       actual travel time, 6                                               discharge planning option communication log, 11
       discharge planning option, 6                                        discharge planning option instructions–
       PASRR, 6                                                             post discharge services, 10
       reasonable placement efforts, 3–5                                   explanation of form items, 6–9
   TAR Criteria for DP/NF                                                  post discharge community services, 2–3
   authorization, 1–3                                               TAR Discharge Planning Option Codes,
TAR Criteria for NF Authorization (Valdivia v. Coye),                P2: DME HOM IP MTR THP tar dis cod
 P2: AUD DME IP LTC OAP PSY REH THP tar crit nf                        DME purchase or rental allowance without prior
   authorization requirements, 1–2                                      authorization, 1–10
   inclusive and exclusive services, 3–4                               durable medical equipment, 1
   inclusive and exclusive services chart, 13–14                    TAR Discharge Planning Option for Long Term Care,
   key questions: when to submit a TAR, 12                           P2: HOM IP LTC MTR tar dis ltc
   medical necessity and attain or maintain therapy services           Medicare/Medi-Cal crossover patients, 2–4
    chart, 15                                                          post discharge nursing facility services, 1
   medical transportation, 5                                           where to submit the 20-1 TAR form, 2
   occupational, physical, speech therapy: TAR                      TAR Field Office Addresses, P2: ADU AUD CAH
    documentation, 5–7                                               DIA DME HER HOM HOS IP LTC MS MTR OAP
   psychiatric therapy: TAR documentation, 8–11                      PH PSY REH THP tar field
TAR Deferral/Denial Policy (Frank v. Kizer),                           BCCTP, 1
 P2: ADU AUD CAH DIA DME HER HOM HOS IP                                EPSDT program, 1
 LTC MS MTR OAP PH PSY REH THP VC tar defer                            Family PACT, 2
   acute continuing care services, 3–5                                 Medi-Cal In-Home Operations, 3
   general provisions, 5                                               where to submit claims, 4–11
   Memorandum of Understanding (MOU), 1
   non-acute continuing care services, 1–3, 6–16




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
80 Section Titles/Headings Index
TAR for Long Term Care: 20-1 Form, P2: LTC tar ltc                  TAR Overview, P1: tar
   adjudication response (AR), 2                                       authorization for vision care providers, 2
   admission to nursing facility Level B certified for                 common TAR and claim completion errors, 12
     Medi-Cal only, 9                                                  core services, 6
   admitting a recipient from a delegated acute hospital               Frank v. Kizer, 12
     without on-site review, 8                                         eTAR submission guidelines, 8
   admitting a recipient from an acute care hospital with              "from-through" TAR authorization, 10
     on-site review participating in DPO, 8                            initial and reauthorization TARs, 4–5
   admitting a recipient from the community or another                 Manual of Criteria for Medi-Cal Authorization, 11
     nursing facility, 7                                               Medi-Cal authorization forms, 3–4
   authorization for Medicare/Medi-Cal crossover                       out-of-state providers, 11
     recipients, 10                                                    regionalized services, 6
   field office jurisdiction, 5                                        resubmission due to change in rendering provider, 8
   initial LTC TAR submission requirements, 1–2                        returned/forwarded TARs, 9
   LTC TAR authorization time period, 3–5                              submitting claims for TAR-authorized services, 14
   medical records, 6                                                  TAR appeals, 14
   medical transportation, 6                                           TAR deferral policy, 11
   Medicare/Medi-Cal crossover recipients, 10                          TAR information requirements, 2
   reauthorization, 2                                                  TAR notice sent to recipients, 14
   timeliness, 5                                                       TARs in "history" status, 13
TAR for Long Term Care (Form 20-1): Inpatient                          TAR status inquiry and Provider Telecommunications
 Services, P2: IP tar ltc ip                                            Network, 14
   20-1 LTC TAR claim instructions, 4–5                                TAR status on adjudication response (AR), 9
   discharging a recipient from a delegated acute hospital             TAR submission methods, 7
     without on-site review, 2                                         TAR transmittal forms, 4
   discharging a recipient from an acute care hospital with            where to submit TARs, 6
     on-site review participating in DPO, 3                         TAR Request for Extension of Stay in Hospital
   glossary, 1–2                                                     (Form 18-1), P2: IP tar req ext
TAR for Long Term Care: MDS Form,                                      adjudication response (AR), 2
 P2: LTC tar ltc mds                                                   day of admission definition, 1
   minimum data set for nursing home resident assessment               elective acute admissions, 2
     and screening (MDS 2.0), 1–15                                     emergency admissions (18-1 TAR), 1–3
                                                                       explanation of form items, 4–9
                                                                    TAR Submission: Clock-Stop Fax Transmittal Form,
                                                                     P2: ADU AUD CAH DIA DME HER HOM HOS
                                                                     LTC MS MTR OAP PSY REH THP tar sub clk
                                                                       explanation of form items, 2–3




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP    All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU   ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID   AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH   Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA   Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP   EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER   Heroin Detoxification
PSY   Psychological Services                                        HOM   HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS   Hospice Care

Indexes and Glossary
                                                                                                                 July 2011
                                                                          Section Titles/Headings Index 81
TAR Submission: Drug TARs, P2: PH tar sub drug                      Transplants, P2: CAH GM IP transplant
   appeal of denied TAR, 2                                             Bone Marrow Transplants
   drug TAR percent variance, 3–5                                         billing requirements, 10
   faxing drug TARs, 1–2                                               Liver Transplants
   reauthorization of previously approved TAR, 2                          authorization, 11
TAR Submission: Transmittal Form, P2: ADU AUD                             maximum reimbursement, 11
 CAH DIA DME HER HOM HOS IP LTC MS MTR                                 Pancreas Transplants
 OAP PH PSY REH THP tar submis                                             physician services, 12
   explanation of form items, 2–3                                      Policy and Billing Overview
TAR: Submitting Appeals, P2: ADU AUD CAH DIA                              authorization, 1–2
 DME HER HOM HOS IP LTC MS MTR OAP PH                                     billing for services to transplant donor, 3
 PSY REH THP tar submit                                                   billing for services to transplant recipient, 3
   TAR appeals, 1–2                                                       bill using recipient's ID number, 2
Taxable and Non-Taxable Items,                                            claim completion fields: donor and recipient, 4–6
 P2: AUD DME OAP PH tax                                                   introduction: important, 1
   hearing aid purchase, 3                                                organ procurement, 7–8
   modifiers for hearing aids, 1                                          procedure codes: inpatient services claim
   non-deliverable items, 2                                                 completion, 5
   sales tax for hearing aid and orthotic appliance repairs, 3            proof of eligibility, 1
   sales tax for replacement parts, 2                                     reimbursement restrictions, 9
   sales tax information, 1                                               separate claims: other physician services, 2
   sales tax on rentals, 2                                                separate claims: recipient and donor, 2
   TAR requirements for hearing aids, 2                                Simultaneous Kidney Pancreas Transplant
                                                                           physician services, 12
                                                                       Small Bowel and Combined Liver and
                                                                        Small Bowel Transplants
                                                                          billing, 12
                                                                          physician services, 12




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011
82 Section Titles/Headings Index
Transplants: Billing Examples for Inpatient                         UB-04 Special Billing Instructions for
 Services, P2: CAH GM IP transplant ex ip                            Outpatient Services, P2: OP ub spec op
   billing tips, 1                                                     billing TAR and non-TAR authorized procedures, 6
   inpatient claim for double lung transplant: two                     "by report" attachments, 1
    donors, 2–10                                                       "from-through" billing, 2–3
   inpatient provider billing for bone marrow                          identical services billed for the same date of service, 7
    procurement submits outpatient claim, 11–13                        line-item billing, 3
Transplants: Donor Protocol, P2: IP transplant proto                   submitting claims for TAR-authorized services, 4
organ and tissue donor protocols, 1                                    submitting copies of TARs, 5
Tuberculosis Program, P2: CAH MS tuber                                 TARs and Medi-Services, 6
   application forms, 1                                             UB-04 Submission and Timeliness Instructions,
   billing requirements, 3                                           P2: IP OP ub sub
   retroactive eligibility: TB-infected persons, 1                     claims over one year old, 3–6
   TB-related services, 2                                              late billing instructions, 2
                                                                       six-month billing limit, 1
U                                                                      where to submit claims, 1
UB-04 Completion: Inpatient Services, P2: IP ub comp ip             UB-04 Tips for Billing: Inpatient Services,
   explanation of form items, 3–23                                   P2: IP ub tips ip
UB-04 Completion: Inpatient Services Billing Example,                  common billing errors, 1–2
 P2: IP ub comp ip ex                                                  field completion reminders, 2
   billing tips, 1                                                     paper claim form requirements, 4
   surgical pediatric patient, 2–4                                  UB-04 Tips for Billing: Outpatient Services,
UB-04 Completion: Outpatient Services,                               P2: OP ub tips op
 P2: OP ub comp op                                                     common billing errors, 1–2
   explanation of form items, 3–23                                     field completion reminders, 2–3
UB-04 Special Billing Instructions for Inpatient Services,             paper claim form requirements, 4
 P2: IP ub spec ip                                                  Utilization Review: ICF/DD, ICF/DD-H and ICF/DD-N
   abortion services, 1–2                                            Facilities, P2: LTC util review
   day of discharge or death: reimbursement policy, 1                  federal requirements, 2
   denied inpatient days, 5                                            per diem services, 2
   disproportionate share payments:                                    records retention, 1
    inpatient hospital care, 6                                         separately billable services, 2
   emergency room charges, 6
   “from-through” billing, 3
   identical services billed for the same date of service, 6
   newborn infant using mother's ID, 5
   private accommodations, 5
   split billing a hospital stay, 4
   split billing a revenue code, 3
   split billing coinsurance charges, 5




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP      All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA     LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS     MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH     Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH      All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC      All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                    July 2011
                                                                          Section Titles/Headings Index 83
V
Vaccines For Children (VFC) Program,
 P2: CAH DIA MS REH vaccine
 DTaP hepatitis B IPV (Pediarix), 4
 DTaP Hib IPV vaccine (Pentacel), 4
 DTP and DTaP vaccines, 4
 hepatitis A vaccine, 5
 hepatitis B vaccine, 5
 hepatitis B – Hib vaccine (Comvax), 5
                                                  ®
 human papilloma virus bivalent vaccine (Cervarix ), 6
 human papilloma virus quadrivalent vaccine,
            ®
  (Gardisil ), 6
 influenza vaccine, 6
 influenza virus vaccine, live for intranasal use
            ®
   (FluMist ), 7
 measles, mumps and rubella vaccine, live
   (2nd dose only), 7
 measles, mumps, rubella and varicella vaccine, 7
 meningitis vaccines (Menactra or Menveo), 7
 pneumococcal 7- valent conjugate vaccine (prevnar-7), 8
 pneumococcal vaccine, 8
 reimbursement policy, 1
 rotavirus vaccine, 9
 Tdap vaccine, 10




PROVIDER IDENTIFIER KEY (Part 2 manuals)

AH    All Allied Health            IP      All Inpatient Services   OP     All Outpatient Services    OP    All Outpatient Services
ACU   Acupuncture                                                   ADU    ADHC                       LEA   LEA
AUD   Audiology and Hearing Aids   LTC     All Long Term Care       AID    AIDS Waiver Program        MSS   MSSP
CHR   Chiropractic                                                  CAH    Clinics and Hospitals      REH   Rehabilitation Clinics
DME   DME and Medical Supplies     MS      All Medical Services     DIA    Chronic Dialysis Clinics
MTR   Medical Transportation       GM      General Medicine         EAP    EAPC                       PH    All Pharmacy
OAP   Orthotics and Prosthetics    OB      Obstetrics               HER    Heroin Detoxification
PSY   Psychological Services                                        HOM    HHA/HCBS                   VC    All Vision Care
THP   Therapies                                                     HOS    Hospice Care

Indexes and Glossary
                                                                                                                  July 2011

				
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Description: Psychology Billing Invoice document sample