Commonwealth of Massachusetts MassHealth Provider Manual Series Orthotics Manual Subchapter Number and Title 6. Service Codes Page 6-1 Transmittal Letter ORT-23 Date 01/01/12 601 Introduction MassHealth pays for the services represented by the codes listed in Section 602 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 442.000 and 450.000. In addition, a provider may request prior authorization (PA) for any medically necessary orthotic devices. Providers should consult Transmittal Letter ORT- 23 for the specific effective dates of service for the service codes. An orthotics provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Orthotics Manual. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool for service descriptions, applicable modifiers, place- of-service codes, PA requirements, service limits, and pricing and markup information. For certain services that are payable on an individual- consideration (I.C.) basis, the tool will calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which the Division of Health Care Finance and Policy (DHCFP) has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 34.00. The MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool also contains a link to DHCFP regulations .Error codes are available on the website at www.mass.gov/masshealthpubs. Click on Provider Library, then on List of Explanation of Benefits Codes Appearing on the Remittance Advice. To get to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, click on Provider Library, and then select MassHealth Payment and Coverage Guideline Tools. If you want a paper copy of the tool, you can print it from the website, or request a copy from MassHealth Customer Service. See Appendix A of your MassHealth provider manual for applicable contact information. 602 Modifiers Modifiers LT (left side) and RT (right side) have been added to certain service codes. Please refer to the Orthotics and Prosthetics Payment and Coverage Guidelines Tool. 603 Service Codes This section lists codes for services that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid website at www.cms.gov for more detailed descriptions. A5500 A5510 A6535 A6549 L0112 L0172 L0452 A5501 A5512 A6536 A8000 L0113 L0174 L0454 A5503 A5513 A6537 A8001 L0120 L0180 L0456 A5504 A6530 A6538 A8002 L0130 L0190 L0458 A5505 A6531 A6539 A8003 L0140 L0200 L0460 A5506 A6532 A6540 A8004 L0150 L0220 L0462 A5507 A6533 A6541 A9283 L0160 L0430 L0464 A5508 A6534 A6544 K0672 L0170 L0450 L0466 Commonwealth of Massachusetts MassHealth Provider Manual Series Orthotics Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter ORT-23 Date 01/01/12 603 Service Codes (cont.) L0468 L1000 L1810 L2080 L2405 L3020 L3330 L0470 L1001 L1820 L2090 L2415 L3030 L3332 L0472 L1005 L1830 L2106 L2425 L3031 L3334 L0480 L1010 L1831 L2108 L2430 L3040 L3340 L0482 L1020 L1832 L2112 L2492 L3050 L3350 L0484 L1025 L1834 L2114 L2500 L3060 L3360 L0486 L1030 L1836 L2116 L2510 L3070 L3370 L0488 L1040 L1840 L2126 L2520 L3080 L3380 L0490 L1050 L1843 L2128 L2525 L3090 L3390 L0491 L1060 L1844 L2132 L2526 L3100 L3400 L0492 L1070 L1845 L2134 L2530 L3140 L3410 L0621 L1080 L1846 L2136 L2540 L3150 L3420 L0622 L1085 L1847 L2180 L2550 L3160 L3430 L0623 L1090 L1850 L2182 L2570 L3170 L3440 L0624 L1100 L1860 L2184 L2580 L3201 L3450 L0625 L1110 L1900 L2186 L2600 L3202 L3455 L0626 L1120 L1902 L2188 L2610 L3203 L3460 L0627 L1200 L1904 L2190 L2620 L3204 L3465 L0628 L1210 L1906 L2192 L2622 L3206 L3470 L0629 L1220 L1907 L2200 L2624 L3207 L3480 L0630 L1230 L1910 L2210 L2627 L3208 L3485 L0631 L1240 L1920 L2220 L2628 L3209 L3500 L0632 L1250 L1930 L2230 L2630 L3211 L3510 L0633 L1260 L1932 L2232 L2640 L3212 L3520 L0634 L1270 L1940 L2240 L2650 L3213 L3530 L0635 L1280 L1945 L2250 L2660 L3214 L3540 L0636 L1290 L1950 L2260 L2670 L3215 L3550 L0637 L1300 L1951 L2265 L2680 L3216 L3560 L0638 L1310 L1960 L2270 L2750 L3217 L3570 L0639 L1499 L1970 L2275 L2755 L3219 L3580 L0640 L1600 L1971 L2280 L2760 L3221 L3590 L0700 L1610 L1980 L2300 L2768 L3222 L3595 L0710 L1620 L1990 L2310 L2780 L3224 L3600 L0810 L1630 L2000 L2320 L2785 L3225 L3610 L0820 L1640 L2005 L2330 L2795 L3230 L3620 L0830 L1650 L2010 L2335 L2800 L3250 L3630 L0859 L1652 L2020 L2340 L2810 L3251 L3640 L0861 L1660 L2030 L2350 L2820 L3252 L3649 L0970 L1680 L2034 L2360 L2830 L3253 L3650 L0972 L1685 L2035 L2370 L2840 L3254 L3660 L0974 L1686 L2036 L2375 L2850 L3255 L3670 L0976 L1690 L2037 L2380 L2999 L3257 L3671 L0978 L1700 L2038 L2385 L3000 L3260 L3674 L0980 L1710 L2040 L2387 L3001 L3265 L3675 L0982 L1720 L2050 L2390 L3002 L3300 L3677 L0984 L1730 L2060 L2395 L3003 L3310 L3702 L0999 L1755 L2070 L2397 L3010 L3320 L3710 Commonwealth of Massachusetts MassHealth Provider Manual Series Orthotics Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter ORT-23 Date 01/01/12 603 Service Codes (cont.) L3720 L3808 L3919 L3961 L3984 L4055 L4360 L3730 L3900 L3921 L3962 L3995 L4060 L4370 L3740 L3901 L3923 L3967 L3999 L4070 L4386 L3760 L3904 L3925 L3971 L4000 L4080 L4392 L3762 L3905 L3927 L3973 L4002 L4090 L4394 L3763 L3906 L3929 L3975 L4010 L4100 L4396 L3764 L3908 L3931 L3976 L4020 L4110 L4398 L3765 L3912 L3933 L3977 L4030 L4130 L4631 L3766 L3913 L3935 L3978 L4040 L4205 S1040 L3806 L3915 L3956 L3980 L4045 L4210 L3807 L3917 L3960 L3982 L4050 L4350 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Orthotics Manual Transmittal Letter ORT-23 Date 01/01/12 This page is reserved.