Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 236 August 2013 TO: All Providers Participating in MassHealth FROM: Kristin L. Thorn, Acting Medicaid Director RE: Payment for Vaccine Administration and Office Visit Background MassHealth regulations at 130 CMR 433.413(C) and EOHHS regulations at 101 CMR 317.04(1)(d) have prohibited the payment for both vaccine administration and an office visit. For dates of service on and after July 1, 2012, MassHealth began allowing certain modifiers to allow payment for two medically necessary, separately identifiable services/procedures in the appropriate circumstances. See All Provider Bulletin 227 (June 2012) for more information about modifiers. Policy Change Effective for dates of service starting July 1, 2012, MassHealth now allows payment for both vaccine administration and an office visit, provided that the vaccine administration is a medically necessary, separately identifiable service. Under these circumstances, the provider may append modifier 25 to the office visit code. Modifiers Usage It is important that providers use modifiers only when appropriate. Providers continue to be responsible for ensuring that all services furnished are medically necessary and billed appropriately. As defined by the Centers for Medicare & Medicaid Services (CMS), modifiers indicate special circumstances that allow providers to bill code pairs that are otherwise denied when billed together. A modifier may only be appended to a HCPCS/CPT code if the clinical circumstances justify its use. Providers must ensure that documentation in the patient’s records is sufficient to demonstrate that the use of a modifier is appropriate. Providers are obligated to code correctly and refrain from billing inappropriate codes. Providers should consult the CPT code book for additional information about how to appropriately use modifiers. In particular, providers should apply modifier 25 only as follows: (continued on next page) MassHealth All Provider Bulletin 236 August 2013 Page 2 Modifiers Usage (cont.) Modifier 25: Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other procedures/services reported on the same date. The E&M service may be related to the same or different diagnosis as the other procedure(s)/service(s). Claim Submission Providers that submitted claims for dates of service on or after July 1, 2012, for both an office visit code and a vaccine administration code, by using modifier 25, received payment for the office visit and the vaccine administration. Providers with visit and vaccine-related claims that satisfy the criteria for using modifier 25, and that were partially paid, denied, or unbilled since July 1, 2012, may resubmit their claims. Providers should follow the procedures below, which include how to determine whether a claim should be submitted as an original claim, sent through the resubmission process, replaced, or submitted as a special consideration. Deciding If a Claim Should Be Processed As an Original, a Resubmission, a Replacement, or Special Consideration To determine the method of submission, the provider must use the Should Be Processed following guidelines: A. If the claim is within 90 days of the date of service, the claim is considered to be within the timely filing deadline and may be submitted to MassHealth as an original claim. B. If the claim is in a denied status and the date of service is within one year, the claim must go through the resubmission process. C. If the claim is in a paid status with some detail lines paid and some denied and the date of service is within one year, the claim must be replaced. D. If a claim was never submitted because the provider was not aware of MassHealth’s policy, or the claim is in a paid status with denied lines or a denied status and has exhausted the billing timelines, the claim must be handled as a special consideration. Original Claim Within 90 Days of the Date of Service Prepare a new claim using your electronic software (837P) or direct data entry (DDE). Submit the claim to MassHealth as an original with the unbilled line. Make other corrections as needed, including charges, units, etc. A former internal control number (ICN) is not required because the claim will be submitted within 90 days of the date of service. Resubmitting a Claim Within One Year of the Date of Service Providers should resubmit their claims using direct data entry (DDE), regardless of the original claim’s submission type (DDE or 837P). Use the claim search screen to locate the original claim’s ICN. Once the claim is located, click the ICN and choose the “resubmit” button. Click on the procedure tab and then the detail line number to be corrected. Enter the (continued on next page) MassHealth All Provider Bulletin 236 August 2013 Page 3 Resubmitting a Claim Within One Year of the Date of Service (cont.) correct code and modifier, if applicable. Make additional corrections as needed, including charges, units, etc. After the claim is corrected, click the confirmation tab, verify the charges, and click “submit.” Replacing a Claim in a Paid Status Within One Year of the Date of Service Providers who have been paid for the visit with no modifier 25 should follow the guidelines below to replace the claim and affix the modifier. Prepare a replacement claim using your electronic software (837P) or direct data entry (DDE) with appropriate lines from the original claim (both paid and denied). Omit lines that have been denied correctly and should not be resubmitted; add additional lines if necessary, or correct data elements on existing detail lines with the applicable modifier 25 for those claims that have been paid for the visit with no modifier. Identify the ICN of the originally paid claim as the former ICN for the replacement claim. Special Consideration Claims Claims for special consideration must be submitted on a compact disc (CD) in the correct 837 format for visit and vaccine procedures that were not submitted to MassHealth because the provider was unaware of MassHealth policy, as well as for claims that have exhausted the billing timelines to resubmit or replace. The CD should contain only the affected visit and vaccine claims with the applicable modifier and must include a copy of this bulletin. The CD should not contain dates of service before July 1, 2012. To avoid denials for untimely filing, please send the 837 file to the following address: Claims Operations Attn: Karen Pinkham 100 Hancock Street, 6th floor Quincy, MA 02171 Providers have the option to submit special consideration claims via direct data entry (DDE) and indicate delay reason code 11; the provider must attach a copy of this bulletin about the visit and vaccine claim with the DDE submission. Note: Only providers with approved waivers may use a paper claim form, following instructions within the applicable MassHealth guides for submitters of paper claims. Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. Document ends.