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Medi-Cal assigns reimbursement rates to 12 hernia repair service codes

May 23, 2024


The California Department of Health Care Services (DHCS) recently announced it has updated the reimbursement rates for ventral hernia repair services. The new rates are retroactive to January 1, 2023, and apply to CPT codes 49591-49596 and 49613-49618. The California Medical Association (CMA) had advocated for this change.  

Previously, DHCS had not published a fee schedule amount and was paying “by report” requiring physicians to submit medical records on each claim in order to be paid and, typically, with no consistency in the payment amounts. In addition to the administrative burden of this process, the lack of a published reimbursement rate on the Medi-Cal physician fee schedule meant that many Medi-Cal managed care plans were denying payment for these services. 

CMA had first escalated this issue to DHCS in November 2023. DHCS advised that it updated the rates for these 12 codes in its May 2024 provider bulletin. According to DHCS, an erroneous payment correction (EPC) notice will be implemented to automatically reprocess denied and underpaid* claims. DHCS has advised CMA that the estimated implementation date of EPC is theend of August 2024. However, physicians may also resubmit previously denied or underpaid claims as described in the CIF Submission and Timeliness Instructions section of the provider manual.  

*Physicians are reminded that Medi-Cal pays the lesser of the billed charge and the fee schedule amount. Therefore, if your billed charge was less than the new established payment amount, Medi-Cal will not pay any additional money on those claims. 

 

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