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-20 January 2009 TO: Acute Outpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Subchapter 6 for 2009 HCPCS) This letter transmits revisions to the service codes in Subchapter 6 of the Acute Outpatient Hospital Manual. Revisions are effective for all claims with dates of service on or after January 1, 2009. This letter also updates billing information for acute outpatient hospitals (AOHs), including their hospital-licensed health centers and other provider-based satellites. Revised Subchapter 6 (Service Codes) Providers should use the revised Subchapter 6 along with the American Medical Association Current Procedural Terminology (CPT) 2009 Healthcare Common Procedure Coding System (HCPCS) Level II code book. Subchapter 6 of the Acute Outpatient Hospital Manual contains the following information. . CPT codes that are not billable under the MassHealth acute outpatient hospital program (all other CPT codes in the CPT 2009 code book are billable, subject to all limitations and conditions of payment in MassHealth regulations at 130 CMR 410.000 and 450.000); and . Level II HCPCS that are billable under the MassHealth acute outpatient hospital program. An AOH provider may request prior authorization (PA) 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 or other provider manuals referred to in this transmittal letter. The revised Subchapter 6 applies only when billing for services that are paid either according to the Payment Amount Per Episode (PAPE) methodology, or according to the Division of Health Care Finance and Policy (DHCFP) Clinical Laboratory Fee Schedule (114.3 CMR 20.00). MassHealth providers must refer to the official list of CPT and HCPCS codes with descriptions, as posted on the Centers for Medicare & Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. Vaccines Provided in an AOH Setting Vaccines supplied by the Massachusetts Department of Public Health (DPH) free of charge are not reimburseable by MassHealth. Information about the availability of DPH-supplied vaccines can be found at the following DPH Web sites: http://www.mass.gov/dph http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability_adult.pdf http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability_childhood.pdf MassHealth reimburses AOH providers for vaccines not supplied by DPH and not listed in Subchapter 6 of the Acute Outpatient Hospital Manual. Reminder to Use a Modifier When Billing for Behavioral Health Screening Tools The administration and scoring of standardized behavioral-health screening tools, selected from the approved menu of tools found in Appendix W of your MassHealth 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 in Section 604 to indicate whether a behavioral-health need was identified. "Behavioral-health need identified" means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need. In the future, failure to include a modifier when billing Service Code 96110 will result in denial of the claim. Reminder to Submit Professional Claims for Drugs with NDC Codes All professional claims are required to have NDC codes, as well as units and descriptors effective January 1, 2009. Revised Subchapter 6 For services provided by acute outpatient hospitals that are not paid according to the PAPE methodology or according to the DHCFP Clinical Laboratory Fee Schedule, AOHs must refer to the MassHealth provider manuals listed below to determine which services are payable and which are not payable. These provider manuals are available on the MassHealth Web site at www.mass.gov/masshealth. Adult Day Health – AOHs billing for adult day health services must refer to Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must refer to Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must refer to Subchapter 6 of the Transportation Manual. Dental Services – AOHs billing for dental services must refer to Subchapter 6 of the Dental Manual except when the conditions in 130 CMR 420.430(A) or (D) apply. In those instances, AOHs should refer to Subchapter 6 of the Acute Outpatient Hospital Manual. Early Intervention Program – AOHs billing for early intervention program services must refer to Subchapter 6 in the Early Intervention Program Manual. Hearing Aid Dispensing – AOHs billing for the dispensing of hearing aids must refer to Subchapter 6 of the Hearing Instrument Specialist Manual. Home Health Services – AOHs billing for home health services must refer to Subchapter 6 of the Home Health Agency Manual. Physician Services – AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. Psychiatric Day Treatment Program – AOHs billing for psychiatric day treatment programs must refer to Subchapter 6 of the Psychiatric Day Treatment Program Manual. Vision Care Materials Dispensing – AOHs billing for the dispensing of ophthalmic materials must refer to Subchapter 6 of the Vision Care Manual. For more information on the reimbursement for AOH services, providers should refer to the Hospital Rate Year (HRY) 2008 Acute Hospital Request for Application (RFA). Hospitals can find the HRY 2008 RFA as well as regulatory and billing information on the MassHealth Web site at www.mass.gov/masshealth. Questions 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 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages 6-1 through 6-6 — transmitted by Transmittal Letter AOH-19 601 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 0014F 0015F 4002F 4006F 4009F 4011F 0016T 0017T 0019T 0030T 0042T 0048T 0050T 0051T 0052T 0053T 0062T 0063T 0066T 0067T 0068T 0069T 0070T 0071T 0072T 0073T 0075T 0076T 0077T 0078T 0079T 0080T 0081T 0084T 0085T 0086T 0087T 0092T 0095T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0123T 0124T 0126T 0130T 0140T 0141T 0142T 0143T 0144T 0145T 0146T 0147T 0148T 0149T 0150T 0151T 0155T 0156T 0157T 0158T 0159T 0160T 0161T 0163T 0164T 0165T 0166T 0167T 0168T 0169T 0170T 0171T 0172T 0173T 0174T 0175T 0176T 0177T 0178T 0179T 0180T 0181T 0182T 0183T 0184T 0185T 0186T 0187T 0188T 0189T 0190T 0191T 0192T 0193T 0194T 0195T 0196T 0197T 0198T 00100 through 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 21120 21121 21122 21123 21125 21127 21245 21246 21248 21249 22526 22527 22841 22856 22861 22864 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 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 90696 90698 90700 90701 90702 90708 90710 90712 90715 90716 90718 90720 90721 90723 90732 90744 90748 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 93770 93786 94005 94015 94774 94775 94776 94777 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 95992 96000 96001 96002 96003 96004 96150 96151 96152 96153 96154 96155 96376 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 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 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 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 Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4109 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 S0023 S0028 S0077 S0162 S2083 604 Modifiers Modifiers and Descriptionsfor 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 MassHealth 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 his or her professional judgement, identified a child with a potential behavioral health services need. 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 MassHealth 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 MassHealth provider manual and behavioral-health need identified. Modifer for Child and Adolescent Needs and Strengths (CANS) HA Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination Modifiers and Descriptions for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) to report tobacco-cessation counseling. Service Code 99407 may also be billed without a modifier to report an individual smoking and tobacco use cessation counseling visit of at least 30 minutes. HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes This page is reserved.