Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AOH-28 June 2012 TO: Acute Outpatient Hospital Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Acute Outpatient Hospital Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Acute Outpatient Hospital Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. This letter also updates billing information for acute outpatient hospitals (AOH), including their hospital-licensed health centers and other provider-based satellites. Service Codes for Subchapter 6 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). Providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2012, or Ingenix HCPCs Level II Codebook for the service code descriptions. 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. Subchapter 6 (Other Provider Manuals) For services provided by AOHs 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 website at www.mass.gov/masshealth. MassHealth Transmittal Letter AOH-28 June 2012 Page 2 Adult Day Health – AOHs billing for adult day health services must enroll in the Adult Day Health Program and refer to Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must enroll in the Adult Foster Care Program and refer to Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must enroll in the Transportation Program and 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 Services – AOHs billing for early intervention program services must enroll in the Early Intervention Program and refer to Subchapter 6 of 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 enroll in the Home Health Program and refer to Subchapter 6 of the Home Health Agency Manual. Pharmacy Services – 340B qualified AOHs using contract pharmacies and 340B pharmacies with retail licenses must refer to the MassHealth Pharmacy Manual. Physician Services – AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. Psychiatric Day Treatment Services – AOHs billing for psychiatric day treatment services must enroll in the Psychiatric Day Treatment Program and 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) 2010 Acute Hospital Request for Application (RFA). Hospitals can locate the HRY 2010 RFA at www.comm-pass.com. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of 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 paper copy of the publication. The specific regulation title for acute outpatient services is Clinical Laboratory Services: 114.3 CMR 20.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Transmittal Letter AOH-28 June 2012 Page 3 MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about 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 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages 6-1 through 6-12 — transmitted by Transmittal Letter AOH-26 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions posted on the Centers for Medicare & Medicaid Services website at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. For a list of billable revenue codes, please refer to Appendix F of the Acute Outpatient Hospital Manual. 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. Early and Periotic Screening, Diagnosis and Treatment Services (EPSDT) An acute outpatient hospital 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 Subchapter 6 of the Acute Outpatient Hospital Manual. 602 Nonpayable CPT Codes MassHealth does not ordinarily pay for services billed under the following codes and code ranges. 0001F 0052T 0101T 0142T 0051T 0005F 0053T 0102T 0143T 0052T