Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter AOH-19 January 2009 TO: Acute Outpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Outpatient Hospital Manual (Implementation of the Child and Adolescent Needs and Strengths Tool) This letter transmits revisions to the acute outpatient hospital regulations to implement the Child and Adolescent Needs and Strengths (CANS) tool. The CANS is a standardized behavioral-health assessment tool that MassHealth is implementing as part of the Children’s Behavioral Health Initiative (CBHI) for members under the age of 21. These regulations are effective December 26, 2008. Overview of the MassHealth CANS Requirement MassHealth providers who furnish behavioral-health services to MassHealth members under the age of 21 are required to ensure that certain clinicians are certified every two years, according to the process established by MassHealth, to use the CANS, and that those clinicians complete the CANS as part of any comprehensive evaluation before the member starts individual, group, or family therapy, and update the CANS at least every 90 days thereafter as part of the review of the member’s treatment plan. For each CANS conducted, these providers are required to document the data collected during the assessment in the member’s medical record and report it to MassHealth in a specified manner and format. Description of the CANS Tool MassHealth has developed two versions of the CANS tool: “CANS Birth through Four” and “CANS Five through Twenty.” In addition to the CANS assessment questions, both forms allow the clinician to record the determination of whether the member has a serious emotional disturbance (SED). Providers can access the two CANS forms, as well as frequently asked questions relating to them, on the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. The CBHI Web site also includes a bibliography of published papers and other resources on the CANS approach. CANS Requirements for Acute Outpatient Hospitals The following qualified clinicians at acute outpatient hospitals who provide individual, group, or family therapy to members under the age of 21 must complete the CANS during the initial behavioral-health assessment before the initiation of therapy and must update it every 90 days thereafter: * psychiatrists and psychiatric residents; * psychologists; * social workers; * psychiatric nurse mental-health clinical specialists; and * counselors. The CANS is not required during an assessment that is conducted as part of an emergency department screening. Acute outpatient hospitals are required to verify for a sample of cases, as part of a utilization review plan, that the CANS was completed at the initial behavioral-health assessment and updated at least every 90 days thereafter. The medical record of each member under the age of 21 must include a CANS completed at the initial behavioral-health assessment and updated at least every 90 days thereafter. In addition, for each CANS conducted, acute outpatient hospitals must ensure that the data collected is reported to MassHealth in the format that is specified in the section entitled “CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application.” Completion of the CANS for Members Currently Receiving Therapy If a member has an ongoing relationship with an acute outpatient hospital to receive individual, group, or family therapy before the effective date of these regulations, it is not necessary to perform another initial assessment, including the CANS, or to update the CANS every 90 days thereafter when the treatment plan is reviewed for that member. However, if the member leaves treatment and subsequently returns for a new course of treatment, it is necessary to perform a new initial assessment, using the CANS for that member, and to update the CANS every 90 days thereafter. CANS Certification and Training Requirements Clinicians who are required to use the CANS must be certified every two years by passing an online CANS certification examination. Bachelors-level direct service providers or paraprofessionals will not be trained or certified in the CANS. Certified clinicians can use both versions of the Massachusetts CANS: “CANS Birth through Four” and “CANS Five through Twenty.” MassHealth is offering online and in-person training opportunities to assist clinicians with the certification process. The in-person training is being conducted by the University of Massachusetts Medical School on various dates across the state. Participation in both the in-person and online training will be free of charge and will include free Continuing Education Units (CEUs). Participation is voluntary, but encouraged. It is not necessary to participate in training in order to take the certification exam. Information about the CANS training and certification exam can be found on the Web at https://masscans.ehs.state.ma.us. This Web site provides access to the online training, the online certification exam, and the schedule of the in- person training sessions. For more information about CANS training or certification, please contact the Massachusetts CANS Training Center by calling 508-856-1016 or e-mailing Mass.CANS@umassmed.edu. CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application MassHealth has developed a new Web-based application that permits providers to enter and view CANS data in a secure environment, subject to consent by the member, his or her custodial parent, or other authorized individual. The CANS application is accessible through the Executive Office of Health and Human Services (EOHHS) Virtual Gateway (VG) Web portal. MassHealth is rolling out the online CANS application in two stages. The first release was in December 2008. It allows users to develop familiarity with the application and asks users to document certain member demographic information and answer the questions that determine if the member has a serious emotional disturbance (SED). The second release, which is expected in the spring of 2009, will add the rest of the assessment questions from the two versions of the CANS tool. With the CANS application available online, acute outpatient hospitals are required to use this application each time the CANS is completed or updated to satisfy their CANS data reporting requirements. Until the second release of the online CANS application, which is expected in the spring of 2009, the CANS must be completed on paper and be included in the member’s medical record. Once the second release occurs, providers can choose to include a copy of the CANS in either an electronic or paper form in the member’s medical record. However, providers must be sure to exercise one of these options. At no point should a CANS form be mailed to EOHHS or MassHealth. The CANS forms are available at the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. This link will take you to PDF and RTF (for screen readers for the visually disabled) versions of the two CANS forms. Acute outpatient hospitals can obtain updated information about the release schedule of the CANS application on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Providers should check this site regularly for updated information. In order to use the online CANS application, acute outpatient hospitals must ensure that the facility is enrolled with the VG and that each clinician who will be entering and viewing data in the CANS application has his or her own VG user ID. In addition, the CANS application will allow data entry operators to perform certain functions on behalf of clinicians. Each data entry operator also needs his or her own VG user ID. Enrollment with the VG for other business applications, such as STARS or EIM/EIS, does not satisfy this requirement. For assistance in the process in obtaining access to the CANS application, acute outpatient hospitals should send the following information to VirtualGatewayCBHI@state.ma.us: * the name of the facility or organization; * the name, address, phone, and e-mail address for a CANS point-of-contact at the organization who is being identified to work with the Virtual Gateway Deployment Unit; * a statement indicating whether or not the organization has access to the VG Web portal (yes or no); * the number of clinicians who need access to the CANS application; and * a statement indicating whether or not anyone in the organization has completed the CANS training. (If yes, provide the number of individuals who have completed the training.) If you have any comments or concerns about the VG enrollment process or technical questions about the CANS application, please send them to VirtualGatewayCBHI@state.ma.us. MassHealth is developing job aids and interactive flash files for the CANS application. There will be a job aid explaining how to log onto the application. Also, there will be separate job aids for clinicians, data entry operators, and provider organization staff to help them use and navigate the various functions that they have access to in the system. The job aids will be available on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. In addition, for clinicians registered on the VG, the job aids and flash files will be transmitted electronically from the VG Team to provide instruction on the application. Payment for CANS: Service Code 90801-HA For dates of service on or after November 30, 2008, acute outpatient hospitals should bill for the initial behavioral-health assessment that includes the CANS as a psychiatric diagnostic interview examination, using Service Code 90801 with the modifier HA. To implement this requirement, the modifier HA for Service Code 90801 has been added to Subchapter 6 of the acute outpatient hospital manual, under “Modifiers.” The review and updating of the CANS required every 90 days for members in ongoing individual, group, or family therapy is part of treatment planning and documentation. As such, it is not a separately billable service. Contact Numbers If you need technical assistance with the VG, you may contact VG Customer Assistance at 1-800-421-0938, ext. 5. If you have questions about CANS training or certification, contact the Massachusetts CANS Training Center at 508-856-1016 or e-mail your questions to Mass.CANS@umassmed.edu. If you have any questions about the information in this transmittal letter 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. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Outpatient Hospital Manual Pages iv-a, 4-45 through 4-50, 4-53, 4-54, and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Page iv-a — transmitted by Transmittal Letter AOH-18 Pages 4-45 through 4-50, 4-53, and 4-54 — transmitted by Transmittal Letter AOH-10 Pages 6-1 through 6-6 — transmitted by Transmittal Letter AOH-17 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv-a Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 4. Program Regulations (cont.) 410.455: Laboratory Services: Introduction 4-34 410.456: Laboratory Services: Payment 4-34 410.457: Laboratory Services: Request for Services 4-35 410.458: Laboratory Services: Recordkeeping Requirements 4-35 410.459: Laboratory Services: Specimen Referral 4-36 (130 CMR 410.460 Reserved) 410.461: Pharmacy Services: Prescription Requirements 4-37 410.462: Pharmacy Services: Covered Drugs and Medical Supplies for MassHealth Members 4-38 410.463: Pharmacy Services: Limitations on Coverage of Drugs 4-39 410.464: Pharmacy Services: Drugs and Medical Supplies Provided by Hospital-Based Pharmacies 4-41 410.465: Pharmacy Services: Drugs and Medical Supplies for Members in Institutions 4-41 410.466: Pharmacy Services: Prior Authorization 4-42 410.467: Pharmacy Services: Member Copayments 4-42 410.468: Participation in the 340B Drug-Pricing Program for Outpatient Pharmacies 4-43 (130 CMR 410.469 and 410.470 Reserved) 410.471: Mental Health Services: Introduction 4-44 410.472: Mental Health Services: Noncovered Services 4-44 (130 CMR 410.473 Reserved) 410.474: Mental Health Services: Definitions 4-45 410.475: Mental Health Services: Staffing Requirements 4-46 410.476: Mental Health Services: Treatment Procedures 4-48 410.477: Mental Health Services: Utilization Review Plan 4-48 410.478: Mental Health Services: Recordkeeping Requirements 4-49 410.479: Mental Health Services: Service Limitations 4-50 410.480: Mental Health Services: Child and Adolescent Needs and Strengths (CANS) Data Reporting 4-53 410.481: Vision Care Services: General Requirements 4-54 410.482: Vision Care Services: Prescription and Dispensing Requirements 4-55 410.483: Vision Care Services: Recordkeeping Requirements 4-56 410.484: Vision Care Service Limitations: Visual Analysis 4-57 410.485: Vision Care Service Limitations: Dispensing Eyeglasses 4-57 410.486: Vision Care Service Limitations: Lenses 4-58 410.487: Vision Care Service Limitations: Other Restrictions 4-59 410.488: Vision Care Service Exclusions 4-60 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-45 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 410.474: Mental Health Services: Definitions The following terms used in 130 CMR 410.471 through 410.479 will have the meanings given in 130 CMR 410.474 unless the context clearly requires a different meaning. When provided in a hospital outpatient department, services that are defined below must conform to the definitions given. (A) Case Consultation – a preplanned meeting of at least one-half hour's duration concerning a member who is either (1) a client of the hospital outpatient department to whom it is the primary provider of therapeutic services; or (2) one for whom evaluation and assessment have been requested by another agency or program involved in treatment or management of the member. (B) Child and Adolescent Needs and Strengths (CANS) – a tool that provides a standardized way to organize information gathered during behavioral-health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment tool for behavioral-health providers serving MassHealth members under the age of 21. (C) Couple Therapy – therapeutic services provided to a couple whose primary complaint is the disruption of their marriage, family, or relationship. (D) Crisis Intervention/Emergency Services – immediate mental health evaluation, diagnosis, hospital prescreening, treatment, and arrangements for further care and assistance as required, provided during all hours to clients showing sudden, incapacitating emotional stress. The MassHealth agency will pay only for face-to-face contact; telephone contacts are not reimbursable. (E) Diagnostic Services – the examination and determination of a patient's physical, psychological, social, economic, educational, and vocational assets and disabilities for the purpose of designing a treatment plan. (F) Family Consultation – a preplanned meeting with the parent or parents of a child who is being treated, when the parent or parents are not clients. (G) Family Therapy – the treatment of more than one member of a family simultaneously in the same session. (H) Group Therapy – the application of psychotherapeutic or counseling techniques to a group of persons, most of whom are not related by blood, marriage, or legal guardianship. (I) Home Visit – crisis intervention, individual, group, or family therapy, and medication provided in the member's residence (excluding a medical institution), when the member is unable to be served at the hospital outpatient department. (J) Individual Therapy – therapeutic services provided to an individual. (K) Long-Term Therapy – a combination of diagnostics and individual, couple, family, and group therapy planned to last more than 17 sessions. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-46 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 (L) Medication Visit – a member visit specifically for prescription, review, and monitoring of medication by a psychiatrist or administration of prescribed intramuscular medication by qualified personnel. (M) Psychological Testing – the use of standardized test instruments to evaluate aspects of an individual's functioning, including aptitudes, educational achievements, cognitive processes, emotional conflicts, and type and degree of psychopathology, subject to the limitations of 130 CMR 410.479(H). (N) Short-Term Therapy – a combination of diagnostics and individual, couple, family, and group therapy planned to end within 17 sessions. 410.475: Mental Health Services: Staffing Requirements (A) Provider Responsibilities. (1) The hospital outpatient department must employ a balanced interdisciplinary staff to furnish mental health services under the direction of a licensed psychiatrist. (2) The hospital outpatient department must designate a professional staff member as director of clinical services and a licensed psychiatrist as medical director. (3) A licensed psychiatrist must be on call during all hours of operation. (4) Although the MassHealth agency does not require that the hospital outpatient department employ mental health professionals from all the disciplines listed in 130 CMR 410.475(B), staff members who provide services to members must be qualified as set forth in 130 CMR 410.475(B) for their respective disciplines. (B) Staff Qualifications. (1) Psychiatrist. At least one staff psychiatrist must be either currently certified by the American Board of Psychiatry and Neurology or eligible for such certification. Any additional psychiatrists must be, at the minimum, licensed physicians in their second year of a psychiatric residency program accredited by the Council on Medical Education of the American Medical Association. Such physicians must be under the direct supervision of a licensed psychiatrist. Any psychiatrist or psychiatric resident who provides individual, group, or family therapy to members under the age of 21 must be certified every two years to administer the CANS, according to the process established by the Executive Office of Health and Human Services (EOHHS). (2) Psychologist. At least one staff psychologist must be licensed by the Massachusetts Board of Registration of Psychologists with a specialization listed in clinical or counseling psychology or a closely related specialty. Additional staff members trained in the field of clinical or counseling psychology or a closely related specialty must(a) have a minimum of a master's degree or the equivalent graduate study in clinical or counseling psychology or a closely related specialty from an accredited educational institution; (b) be currently enrolled in or have completed a doctoral program in clinical or counseling psychology or a closely related specialty; (c) have had two years of full-time supervised clinical experience subsequent to obtaining a master's degree in a multidisciplinary mental health setting. (one year of supervised clinical work in an organized graduate internship program may be substituted for each year of experience); and Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-47 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 (d) for any psychologist who provides individual, group, or family therapy to members under the age of 21, be certified every two years to administer the CANS, according to the process established by the Executive Office of Health and Human Services (EOHHS). (3) Social Worker. (a) At least one staff social worker must be licensed or have applied for and have a license pending as an independent clinical social worker by the Massachusetts Board of Registration of Social Workers. (b) Any additional social workers on the staff must provide services under the direct and continuous supervision of an independent clinical social worker. Such additional social workers must be licensed or applying for licensure as certified social workers by the Massachusetts Board of Registration of Social Workers and have received a master's degree in social work and completed two years of full-time supervised clinical work in an organized graduate internship program. (c) Any social worker who provides individual, group, or family therapy to members under the age of 21 must be certified every two years to administer the CANS, according to the process established by the Executive Office of Health and Human Services (EOHHS). (4) Psychiatric Nurse. At least one psychiatric nurse must be currently registered by the Massachusetts Board of Registration in Nursing and must have a master's degree in nursing from an accredited National League of Nursing graduate school with two years of full-time supervised clinical experience in a multidisciplinary mental health setting and be eligible for certification as a clinical specialist in psychiatric/mental health nursing by the American Nursing Association. Any other nurses must have a bachelor's degree from an educational institution accredited by the National League of Nursing and two years of full- time supervised skilled experience in a multidisciplinary mental health setting subsequent to that degree, or a master's degree in psychiatric nursing. Any psychiatric nurse mental-health clinical specialist who provides individual, group, or family therapy to members under the age of 21 must be certified every two years to administer the CANS, according to the process established by the Executive Office of Health and Human Services (EOHHS). Nurses who are not psychiatric nurse mental-health clinical specialists are not eligible to administer the CANS. (5) Counselor. A counselor must have a master's degree in counseling education, counseling psychology, or rehabilitation counseling from an accredited educational institution and two years of full-time supervised clinical experience in a multidisciplinary mental health setting subsequent to obtaining the master's degree (one year of supervised clinical work in an organized graduate internship program may be substituted for each year of full- time experience). Any counselor who provides individual, group, or family therapy to members under the age of 21 must be certified every two years to administer the CANS, according to the process established by the Executive Office of Health and Human Services (EOHHS). (6) Occupational Therapist. An occupational therapist must be currently licensed by the Massachusetts Division of Registration of Allied Health Professions and registered by the American Occupational Therapy Association and must have either (a) a master's degree in occupational therapy from an accredited program in occupational therapy; or (b) a bachelor's degree in occupational therapy from an accredited program in occupational therapy and a master's degree in a related field such as psychology, social work, or counseling. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-48 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 410.476: Mental Health Services: Treatment Procedures (A) A professional staff member must conduct a comprehensive evaluation of each member prior to initiation of therapy. For members under the age of 21, a CANS must be completed during the initial behavioral-health assessment before initiation of therapy and be updated at least every 90 days thereafter by a CANS-certified provider, as described in 130 CMR 410.475(B). The CANS is not required during an assessment that is conducted as part of the emergency department screening. (B) The hospital outpatient department must accept for treatment, refer for treatment elsewhere, or both, any member for whom the intake evaluation substantiates a mental or emotional disorder. (C) The hospital outpatient department will ensure that one professional staff member (the primary therapist) assumes primary responsibility for each member. This responsibility will include (1) within four client visits, preparation of a comprehensive written treatment plan that is based on the initial evaluation, incorporates short- and long-term treatment goals, and establishes criteria for determining when termination of treatment is appropriate; (2) ongoing utilization review; (3) review of each case at termination of treatment and preparation of a termination summary that describes the course of treatment and any aftercare program or resources in which the member is expected to participate; and (4) ensuring that a CANS-certified provider, as described in 130 CMR 410.475(B), completes the CANS in accordance with 130 CMR 410.476(A). (D) The hospital outpatient department will make provisions for responding to persons needing services on a walk-in basis. (E) The hospital outpatient department will take appropriate steps to facilitate uninterrupted and coordinated member care whenever it refers a member elsewhere for concurrent or subsequent treatment. (F) Before referring a member elsewhere, the hospital outpatient department will, with the member's consent, send a summary of or the actual record of the member to that referral provider. 410.477: Mental Health Services: Utilization Review Plan A mental health program must have a utilization review plan that is acceptable to the MassHealth agency and that meets the following conditions. (A) A utilization review committee will be formed, composed of the clinical director (or a designee), a psychiatrist, and one other professional staff member from each core discipline represented who meets all the qualifications for the discipline, as outlined in 130 CMR 410.475. (B) The utilization review committee will review a representative sample of cases at least in the following circumstances: (1) within 90 days after initial contact; (2) when a member has required more than 50 visits every 12 months and has not required hospitalization or extensive crisis intervention during that period; and (3) following termination. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-49 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 (C) The utilization review committee will verify for a representative sample of cases that (1) the diagnosis has been adequately documented; (2) the treatment plan is appropriate and specifies the methods and duration of the projected treatment program; (3) the treatment plan is being or has been carried out; (4) the treatment plan is being or has been modified as indicated by the member's changing status; (5) there is adequate follow-up when a member misses appointments or drops out of treatment; (6) there is progress toward achievement of short- and long-term goals; and (7) for members under the age of 21, the CANS has been completed at the initial behavioral-health assessment and updated at least every 90 days thereafter as part of the treatment plan review. (D) No staff member will participate in the utilization review committee's deliberations about any member that staff member is treating directly. (E) The program will maintain minutes that are sufficiently detailed to show the decisions of each review and the basis on which any decisions are made so that the MassHealth agency may conduct such audits as it deems necessary. (F) Based on the utilization review, the director of clinical services or a designee will determine whether continuation, modification, or termination of treatment is necessary and promptly communicate this decision to the primary therapist. 410.478: Mental Health Services: Recordkeeping Requirements (A) The hospital outpatient department must obtain, upon the initiation of treatment, written authorization from each member or the member's legal guardian to release information obtained by the provider to hospital staff, federal and state regulatory agencies, and, when applicable, referral providers, to the extent necessary to carry out the purposes of the program and to meet regulatory requirements, including provider audits. (B) In addition to the information required in 130 CMR 410.409, each member's record must include the following information: (1) the member's case number, address, telephone number, sex, age, marital status, next of kin, and school or employment status (or both); (2) the date of initial contact and, if applicable, the referral source; (3) a report of a physical examination performed within six months (if such an examination has not been performed in that period, one must be given within 30 days after the member's request for services or, if the member refuses to be examined, the record must document the reasons for the exam postponement); (4) the name and address of the member's primary physician or medical clinic (a physician or medical clinic must be recommended if there is not one currently attending the member); Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-50 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 (5) a description of the nature of the member's condition; (6) the relevant medical, social, educational, and vocational history; (7) a comprehensive functional assessment of the member; (8) the clinical impression of the member and a diagnostic formulation, including a specific diagnosis using ICD-9-CM or DSM III diagnosis codes; (9) the member's treatment plan, updated as necessary, including long-range goals, short-term objectives, and the proposed schedule of therapeutic activities; (10) a schedule of dates for utilization review to determine the member's progress in accomplishing goals and objectives; (11) the name, qualifications, and discipline of the primary therapist; (12) a written record of utilization reviews by the primary therapist; (13) documentation of each visit, including the member's response to treatment, written and signed by the person providing the service, and including the therapist's discipline and degree; (14) all information and correspondence regarding the member, including appropriately signed and dated consent forms; (15) a medication-use profile; (16) when the member is discharged, a discharge summary; and (17) for members under the age of 21, a CANS completed during the initial behavioral-health assessment and updated at least every 90 days thereafter. (C) A brief history is acceptable for emergency or walk-in visits when the treatment plan does not call for extended care. 410.479: Mental Health Services: Service Limitations (A) Length and Frequency of Sessions. (1) The MassHealth agency will pay for diagnostic and treatment services only when a professional staff member personally provides these services to the member or the member's family, or personally consults with a professional outside of the hospital outpatient department. The services must be provided to the member on an individual basis. (2) The MassHealth agency will pay for only one session of the types of services listed in 130 CMR 410.479(C) through (H) provided to an individual member on one date of service. Return visits on the same date of service are not reimbursable. (B) Diagnostic Services. Payment for diagnostic services provided to a member is limited to a maximum of four hours or eight units. (C) Individual Therapy. Payment for individual therapy is limited to a maximum of one hour per session per day. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-53 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 (J) Home Visits. (1) The MassHealth agency will pay for intermittent home visits. Payment will also be made for home visits made for diagnostic purposes. (2) Home visits are reimbursable on the same basis as comparable services provided at the hospital outpatient department. Travel time to and from the member's home is not reimbursable. (3) A report of the home visit must be entered into the member's record. (K) Multiple Therapies. The MassHealth agency will pay for more than one mode of therapy used for a member during one week only if clinically justified; that is, when any single approach has been shown to be necessary but insufficient. The need for additional modes of treatment should be documented in the member's record. (L) Outreach Services Provided in Nursing Facilities. The MassHealth agency will pay for diagnostic and treatment services provided in a nursing facility to a member who resides in that nursing facility only in the following circumstances: (1) the nursing facility specifically requests treatment and the member's record at the nursing facility documents this request; (2) the treatment provided does not duplicate services usually provided in the nursing facility; (3) such services are generally available through the hospital outpatient department to members not residing in that nursing facility; and (4) the member either cannot leave the nursing facility or is sufficiently mentally or physically incapacitated to be unable to come to the hospital outpatient department alone. 410.480: Mental Health Services: Child and Adolescent Needs and Strengths (CANS) Data Reporting For each Child and Adolescent Needs and Strengths (CANS) conducted, the hospital must report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations Page 4-54 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 410.481: Vision Care Services: General Requirements (A) Introduction. (1) The regulations in 130 CMR 410.481 through 410.489 establish the requirements and procedures for vision care services provided by hospital outpatient departments. Vision care services are the professional care of the eyes for purposes of diagnosing and correcting refractive errors, analyzing muscular anomalies, and determining pathological conditions. They include eye examinations, vision training, and the prescription and dispensing of ophthalmic materials. Professional and technical services will be provided in accordance with the established standards of quality and health care necessity recognized by the vision care industry and licensing agencies in Massachusetts. (2) MassHealth covers the following services only when provided to eligible MassHealth members under age 21: ophthalmic materials, specifically including, but not limited to, complete eyeglasses or eyeglass parts; the dispensing of ophthalmic materials; contact lenses; and other visual aids, except that this age limitation does not apply to visual magnifying aids for use by members who are both diabetic and legally blind. Visual magnifying aids do not include eyeglasses or contact lenses. (B) Definitions. The following terms used in 130 CMR 410.481 through 410.489 will have the meanings given in 130 CMR 410.481 unless the context clearly requires a different meaning. (1) Dispensing Practitioner – any optician, optometrist, ophthalmologist, or other participating provider authorized by the MassHealth agency to dispense eyeglass frames, lenses, and other vision care materials to members. (2) Optical Supplier – the optical laboratory contracted by the MassHealth agency to supply the following ophthalmic materials and services: (a) eyeglass frames; (b) eyeglass lenses; (c) frame cases; (d) tints, coatings, ground-on prisms, and prisms by decentration; and (e) repair parts. (3) Order – the process by which a dispensing practitioner requests ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. (4) Order Form – the form used by the dispensing practitioner to request ophthalmic materials (completed eyeglasses, repair parts, and other services) from the optical supplier. The required form is specified in the billing instructions in Subchapter 5 of the Outpatient Hospital Manual. (5) Prescriber – any optometrist, ophthalmologist, or other practitioner licensed and authorized to write prescriptions for eyeglass frames, lenses, and other vision care services. (C) Nonreimbursable Circumstances. Vision care services are not reimbursable to a vision care provider when the services were furnished in a state institution, in an inpatient hospital, or in a hospital-affiliated teaching institution, and when the services are among those for which the provider is compensated by the state or institution. (D) Prior Authorization. (1) For certain vision care services specified in 130 CMR 410.484 through 410.487, the MassHealth agency requires the provider to obtain prior authorization as a prerequisite to payment. (2) All prior authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Outpatient Hospital Manual. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the Centers for Medicare and Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. CPT Codes MassHealth pays for services billed using all medicine, radiology, laboratory, surgery, and anesthesia CPT codes in effect at the time of service, except for those codes listed in Section 602 of this subchapter, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Level II HCPCS Codes MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. For a list of billable revenue codes and HCPCS billing combinations, please refer to Appendix F of the Acute Outpatient Hospital Manual. The list in Appendix F is to be used only as a guide. EPSDT An acute outpatient hospital 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 the Acute Outpatient Hospital Manual. 602 Nonpayable Services - CPT MassHealth does not ordinarily pay for services billed under the following codes and code ranges. 0001F 0005F 0012F 4002F 4006F 4009F 4011F 0016T 0017T 0019T 0026T 0027T 0028T 0029T 0030T 0031T 0032T 0041T 0042T 0043T 0046T 0047T 0048T 0049T 0050T 0051T 0052T 0053T 0058T 0059T 0060T 0061T 0062T 0063T 0066T 0067T 0068T 0069T 0070T 0071T 0072T 0073T 0075T 0076T 0077T 0078T 0079T 0080T 0081T 0084T 0085T 0086T 0087T 0088T 0089T 0090T 0092T 0093T 0095T 0096T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0123T Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 602 Nonpayable Services - CPT (cont.) 0124T 0126T 0130T 0137T 0140T 0141T 0142T 0143T 0144T 0145T 0146T 0147T 0148T 0149T 0150T 0151T 0155T 0156T 0157T 0158T 0159T 0160T 0161T 0162T 0163T 0164T 0165T 0166T 0167T 0168T 0169T 0170T 0171T 0172T 0173T 0174T 0175T 0176T 0177T 0178T 0179T 0180T 0181T 0182T 0183T 00100 01999 10040 11922 11950 11951 11952 11954 15781 15782 15783 15786 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15847 15876 15877 15878 15879 17340 17360 17380 19316 19324 19325 19355 19396 20930 20936 20985 20986 20987 21120 21121 21122 21123 21125 21127 21245 21246 21248 21249 22526 22527 22841 32491 32850 32851 32852 32853 32854 32855 32856 33930 33933 33935 33940 33944 33945 34803 36415 36416 36468 36469 36591 36592 36598 37765 37766 41870 41872 43644 43645 43752 43842 43843 43845 44132 44133 44135 44136 44137 44720 44721 47133 47135 47136 47140 47141 47142 47143 47144 47145 47146 47147 48160 48551 48552 48554 48556 50320 50323 50325 50327 50328 50329 50340 50360 50365 50370 50380 51701 51702 58750 58752 58760 58956 58970 58974 58976 59070 59072 59412 59897 61630 61635 61640 61641 61642 62287 63043 63044 65760 65765 65767 65771 65780 65781 65782 69090 71552 72159 72198 73225 76140 76150 76350 76496 76497 76498 77399 78267 78268 78351 80502 82075 82962 86079 86890 86891 86910 86911 86927 86930 86931 86932 86960 86985 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-3 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 602 Nonpayable Services - CPT (cont.) 88036 88037 88040 88045 88099 88125 88333 88334 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89322 89325 89329 89330 89331 89335 89342 89343 89344 89346 89352 89353 89354 89356 90281 90283 90284 90287 90379 90384 90386 90389 90396 90586 90633 90634 90636 90645 90646 90647 90648 90665 90669 90680 90698 90700 90701 90702 90708 90710 90712 90715 90716 90718 90720 90721 90723 90732 90744 90748 90769 90770 90771 90776 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90865 90875 90876 90880 90885 90889 90901 90911 90940 90989 90993 90997 90999 91132 91133 92314 92315 92316 92317 92325 92352 92353 92354 92355 92358 92371 92531 92532 92533 92534 92548 92559 92560 92561 92562 92564 92630 92633 93660 93760 93762 93770 93786 94005 94015 94774 94775 94776 94777 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 96000 96001 96002 96003 96004 96150 96151 96152 96153 96154 96155 96567 96902 96904 97005 97006 97537 97545 97546 97597 97598 97602 97605 97606 97755 97810 97811 97813 97814 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 98969 99000 99001 99002 99024 99026 99027 99050 99051 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99143 99144 99148 99149 99150 99172 99190 99191 99192 99199 99251 99252 99253 99254 99255 99288 99289 99290 99293 99294 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 602 Nonpayable Services - CPT (cont.) 99295 99296 99298 99299 99300 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99406 99408 99409 99411 99412 99420 99429 99441 99442 99443 99444 99450 99455 99456 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99600 99601 99602 99605 99606 99607 603 Payable Services - Level II HCPCS The following Level II HCPCS describe services that are covered by MassHealth for AOHs and hospital-licensed health centers (HLHCs). A4641 A9500 A9502 A9503 A9505 A9512 A9537 G0105 G0108 G0109 G0121 G0270 G0271 J0128 J0129 J0135 J0207 J0348 J0475 J0640 J0740 J1094 J1325 J1327 J1561 J1562 J1566 J1569 J1571 J1620 J1626 J1740 J1742 J1745 J1825 J1830 J1950 J2175 J2260 J2270 J2323 J2357 J2430 J2469 J2550 J2770 J2778 J3110 J3243 J3396 J7321 J7322 J7323 J7324 J7340 J7341 J7342 J7343 J7344 J7346 J7347 J7348 J7349 J7501 J7504 J7505 J7525 J8510 J8520 J8521 J8530 J8560 J8600 J8610 J8700 J9000 J9001 J9015 J9020 J9031 J9035 J9040 J9041 J9045 J9050 J9055 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9100 J9110 J9120 J9130 J9140 J9150 J9151 J9160 J9165 J9170 J9181 J9182 J9185 J9190 J9200 J9202 J9206 J9208 J9209 J9211 J9213 J9214 J9215 J9216 J9217 J9218 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 603 Payable Services - Level II HCPCS (cont.) J9219 J9230 J9245 J9250 J9261 J9265 J9266 J9268 J9270 J9280 J9290 J9291 J9293 J9305 J9320 J9340 J9350 J9355 J9357 J9360 J9370 J9375 J9380 J9390 J9600 J9999 L8614 L8615 L8616 L8617 L8618 L8619 L8690 L8691 S0023 S0028 S0077 S0162 S2083 604 Modifiers Modifiers for Behavioral-Health Screening The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral-health need was identified. “Behavioral- health need identified” means the provider administering the screening tool, in her or his professional judgement, identified a child with a potential behavioral health services need. Modifier-Modifier Description U1 Completed behavioral-health screening using a standardized behavioral- health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified. U2 Completed behavioral-health screening using a standardized behavioral- health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and behavioral-health need identified. Modifier for Child and Adolescent Needs and Strengths (CANS) The following modifier is used in combination with service code 90801 to indicate that the Child and Adolescent Needs and Strengths (CANS) is included in the assessment. Modifier-Modifier Description HA Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Acute Outpatient Hospital Manual Transmittal Letter AOH-19 Date 12/26/08 Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco-cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco use cessation counseling visit of at least 30 minutes. Modifier-Modifier Description HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes