Commonwealth of Massachusetts Executive Office of Health and Human Services Division of Medical Assistance 600 Washington Street Boston, MA 02111 www.mass.gov/dma MASSHEALTH TRANSMITTAL LETTER ABR-13 April 2002 TO: Abortion Clinics Participating in MassHealth FROM: Wendy E. Warring, Commissioner RE: Abortion Clinic Manual (HCPCS Codes) The federal government has revised the HCFA Common Procedure Coding System (HCPCS) for MassHealth billing. This letter transmits changes for your provider manual that contain the new and revised codes. These codes are effective for services provided on or after March 1, 2002. For dates of service on or after March 1, 2002, you must use the new codes in order to receive payment. Please note that you must use a modifier with some codes to accurately reflect the service provided. The attached subchapter 6 contains codes with modifiers, when applicable, along with their service descriptions. If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for Abortion Clinic Services is 114.3 CMR 13.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 This letter also transmits an updated page of the billing instructions, Subchapter 5 of the Abortion Clinic Manual. The sample claim form has been updated to reflect the use of HCPCS codes. NEW MATERIAL (The pages listed here contain new or revised language.) Abortion Clinic Manual Pages vi, 5.3-9, 5.3-10, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Abortion Clinic Manual Pages 5.3-9 and 5.3-10 — transmitted by Transmittal Letter ABR-6 Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter ABR-12 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE vi ABORTION CLINIC MANUAL TRANSMITTAL LETTER ABR-13 DATE 03/01/02 6. SERVICE CODES AND DESCRIPTIONS Introduction.............................................................. 6-1 Service Codes and Descriptions............................................ 6-1 Appendix A. DIRECTORY..................................................... A-1 Appendix B. ENROLLMENT CENTERS ........................................... B-1 Appendix C. THIRD-PARTY LIABILITY CODES................................... C-1 Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE.......................................... W-1 Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES .................. X-1 Appendix Y. REVS CODES/MESSAGES ........................................... Y-1 Appendix Z. EPSDT SERVICES LABORATORY CODES ................................ Z-1 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 5 BILLING INSTRUCTIONS PAGE 5.3-9 ABORTION CLINIC MANUAL "rRANSMITTAL LETTER ABR-13 DATE 03/01102 522 Item-by-Item Instructions for Claim Form No.9 (cont.) Item 38 AUTHORIZED SIGNATURE The claim form must be signed by the provider or by the individual designated by the provider to certify that the information entered on the form is correct. Signatures other than handwritten signatures (for example, those by stamp, typewriter, or computer equipment) are acceptable. Item 39 BILLING DATE Enter in month/day/year order the date on which the claim form is completed. The billing date may not precede any of the dates of service entered on the claim form. Item 40 ADJUSTMENT/RESUBMITIAL Enter an "X" in the "Adjustment" or "Resubmittal" box only when an entry is required by the instructions for correcting a claim. Do not make any entry in. this item without completing Item 41. Item 41 FORMER TRANSACTION CONTROL NO. When an entry is required in this item, enter the 10digit transaction control number (TCN) assigned to the original claim. The TCN appears on the remittance advice that listed the original claim as paid or denied. When resubmitting or adjusting a claim, include all attachments that were required for the original claim. Item 42 FOR OFFICE USE ONLY Leave this item blank. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 5 BILLING INSTRUCTIONS I PAGE 5.3-10 ABORTION CLINIC MANUAL TRANSMITTAL LETTER ABR-13 DATE 03/01102 522 Item-by-Item Instructions for Claim Fonn No.9 (cant.) This section contains an example of a completed claim form for these services. For assistance with a billing situation not explained in the example, contact MassHealth Provider Services at the appropriate address or telephone numbers listed in Appendix A of this manual. ......... (524 through 530 Reserved) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 ABORTION CLINIC MANUAL TRANSMITTAL LETTER ABR-13 DATE 03/01/02 601 Introduction (A) The maximum allowable fee for an abortion service payable to licensed ambulatory abortion clinics is the fee listed in the applicable Division of Health Care Finance and Policy fee schedule or the provider's usual fee or charge, whichever is less. (B) The service codes for contraceptive supplies are in the Division's Family Planning Agency Manual. (C) All claims for induced abortions, except medically induced abortions, must have a completed Certification for Payable Abortion (CPA-2) form attached to the claim form (see 130 CMR 484.008). (D) I.C. indicates that the claim will be paid on an individual-consideration basis. 602 Service Codes and Descriptions Service Code-Modifier Service Description 99213 Office or other outpatient visit for the evaluation and management of an established patient, that requires at least two of these three key components • an expanded problem-focused history • an expanded problem-focused examination • medical decisionmaking of low complexity J2790 Injection, Rho (D) immune globulin, human, one-dose package (when required only; reimbursed at the actual wholesale cost of the serum; a copy of the purchase invoice must be submitted with the claim form) (I.C.) S0190 Mifepristone, oral, 200 mg S0191 Misoprostol, oral, 200 mcg S0199 Medically induced abortion by oral ingestion of medication, including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by Hcg, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion), except drugs 59820 Treatment of missed abortion, completed surgically, first trimester (includes physician's charges and clinic services) 59840 Induced abortion, by dilation and curettage (first trimester) (includes physician's charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59840-TF Induced abortion, by dilation and curettage (second trimester—12.1 through 13.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59840-TG Induced abortion by dilation and curettage (second trimester—14.0 through 18.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia and insertion of cervical dilator, e.g., laminaria; CPA-2 form required) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 ABORTION CLINIC MANUAL TRANSMITTAL LETTER ABR-13 DATE 03/01/02 Service Code-Modifier Service Description 59841 Induced abortion, by dilation and evacuation (first trimester) (includes physician's charges and clinic services; CPA-2 form required) 59841-TF Induced abortion, by dilation and evacuation (second trimester—12.1 through 13.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59841-TG Induced abortion, by dilation and evacuation (second trimester—14.0 through 18.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia, and insertion of cervical dilator, e.g., laminaria; CPA-2 form required) 76805 Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal and maternal evaluation) 76815 limited (fetal size, heart beat, placental location, fetal position, or emergency in the delivery room) This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Physician’s Current Procedural Terminology (CPT) code book.