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 CHC-66
December 2002
TO:      Community Health Centers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      Community Health Center Manual (Revisions to Service Codes and Descriptions)
This letter transmits revisions to the Community Health Center Manual service codes and descriptions. The revised Subchapter 6 is effective for dates of service on or after January 1, 2003. Subchapter 5, Billing Instructions, will be revised and sent under separate cover.
The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2002. New national service codes have been added, and MassHealth local codes have been removed from the Community Health Center Manual. 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, where applicable.
I.	Titmus Vision Test
Effective for dates of service on or after January 1, 2003, the MassHealth local service code for a titmus vision test (X9335) has been replaced with CPT code 99173, screening test of visual acuity, quantitative, bilateral.
II.	Individual Medical Visits
Effective for dates of service on or after January 1, 2003, the MassHealth local service code for an individual medical visit in a CHC (X5902) has been replaced with HCPCS code T1015 (Clinic visit/encounter, all-inclusive). The MassHealth local service code for an individual medical visit with a nurse midwife for a prenatal or postpartum service (X5901) has been replaced with HCPCS code T1015 with modifier TH (obstetrical treatment/services, prenatal or postpartum). The MassHealth local code for group clinic visit (5904) has been replaced with HCPCS code T1015 with modifier HQ (clinic visit/all inclusive/group setting).
In addition, two MassHealth local service codes for HIV counseling visits (X5580 and X5581) have been replaced with a single CPT code 99402 (preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual; separate procedure; approx 30 minutes). Providers are no longer required to differentiate between pre-test and post-test counseling visits for billing purposes.
III.	Billing Guidelines
Please find attached a crosswalk from the obsolete MassHealth local service codes and modifiers to the new national service codes and modifiers for the revised Subchapter 6.

MASSHEALTH
TRANSMITTAL LETTER CHC-66 December 2002 Page 2
IV. How to Obtain a Community Health Centers Fee Schedule with the New Service Codes
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 is 114.3 CMR 4.00: Rates for Community Health Centers.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr
V.  Table of Contents

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

Table of Contents page vii is being updated to include Appendix W, which was added to all provider manuals in May 2001.
VI. Web Site Access and Questions
All of the information in this transmittal letter, as well as the revised regulations, is available on the Division’s Web site at www.mass.gov/dma.
If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Community Health Center Manual
Pages vii, 6.3-1 through 6.3-6, 6.5-1, 6.5-2, 6.8-1, and 6.8-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Community Health Center Manual
Pages vii — transmitted by Transmittal Letter CHC-61
Pages 6.3-1 and 6.3-2 — transmitted by Transmittal Letter CHC-64
Pages 6.3-3 through 6.3-6 — transmitted by Transmittal Letter CHC-60
Pages 6.5-1 and 6.5-2 — transmitted by Transmittal Letter CHC-65
Pages 6.8-1 and 6.8-2 — transmitted by Transmittal Letter CHC-57

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vii	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
Appendix A.	DIRECTORY 		A-1
Appendix B.	ENROLLMENT CENTERS 		B-1
Appendix C.	THIRD-PARTY-LIABILITY CODES 		C-1
Appendix D.	MENTAL HEALTH/SUBSTANCE ABUSE PROGRAM 		D-1
Appendix E.	UTILIZATION MANAGEMENT PROGRAM 		E-1
Appendix F.	ADMISSION GUIDELINES 		F-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
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-1	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions
When claiming payment for visits, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.)

Service Code-Modifier
T1015 90899 T1015-HQ
99402
99050
99054
X2003
X3333
99221
99222
99223
99431

Service Description
CHC Visits
Clinic visit/encounter, all-inclusive (use for individual medical visit)
Unlisted psychiatric service or procedure (use for individual mental health visit)
Clinic visit/encounter, all-inclusive — group setting (use for group clinic visit)
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to
an individual (separate procedure); approx 30 min (use for HIV counseling visits)
Services requested after office hours in addition to basic service (Use for urgent care
Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to 4:00
P.M. This code may be billed in addition to the individual medical visit.)
Services requested on Sundays and holidays in addition to basic services (use for urgent
care Saturday 4:01 P.M. to Monday 6:59 A.M. This code may be billed in addition to the
individual medical visit.)
Dental enhancement fee (This code can only be billed on claim form no. 11, once per
date of service for each member receiving dental services on that date.)
Injectable and infusible drugs and devices supplied in the clinic (P.A.) (I.C.)
Hospital Inpatient Services
Initial hospital care, per day, for the evaluation and management of a patient, that requires these three key components:
-	a detailed or comprehensive history;
-	a detailed or comprehensive examination; and
-	medical decision making that is straightforward or of low complexity Initial hospital care, per day, for the evaluation and management of a patient, that requires these three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of moderate complexity
Initial hospital care, per day, for the evaluation and management of a patient, that requires these three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records (This code should also be used for birthing-room deliveries.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-2	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Service Description
Subsequent Hospital Care
99231	Subsequent hospital care, per day, for the evaluation and management of a patient, that requires at
least two of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	medical decision making that is straightforward or of low complexity
99232	Subsequent hospital care, per day, for the evaluation and management of a patient, that requires at
least two of these three key components:
-	an expanded problem-focused interval history;
-	an expanded problem-focused examination;
-	medical decision making of moderate complexity
99233	Subsequent hospital care, per day, for the evaluation and management of a patient, that requires at
least two of these three key components:
-	a detailed interval history;
-	a detailed examination;
-	medical decision making of high complexity 99433      Subsequent hospital care, for the evaluation and management of a normal newborn, per day
Hospital Observation Services
Initial Observation Care (New or Established Patient)
99218	Initial observation care, per day, for the evaluation and management of a patient, that requires
these three key components:
-	a detailed or comprehensive history;
-	a detailed or comprehensive examination; and
-	medical decision making that is straightforward or of low complexity
99219	Initial observation care, per day, for the evaluation and management of a patient, that requires
these three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of moderate complexity
99220	Initial observation care, per day, for the evaluation and management of a patient, that requires
these three key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-3	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Service Description
Nursing Facility Services
99301	Evaluation and management of a new or established patient involving an annual nursing facility
assessment, that requires these three key components:
-	a detailed interval history;
-	a comprehensive examination; and
-	medical decision making that is straightforward or of low complexity
99302	Evaluation and management of a new or established patient involving a nursing facility
assessment, that requires these three key components:
-	a detailed interval history;
-	a comprehensive examination; and
-	medical decision making of moderate to high complexity
99303	Evaluation and management of a new or established patient involving a nursing facility
assessment at the time of initial admission or readmission to the facility, that requires these three
key components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
Subsequent Nursing Facility Care
99311	Subsequent nursing facility care, per day, for the evaluation and management of a new or
established patient, that requires at least two of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	medical decision making that is straightforward or of low complexity
99312	Subsequent nursing facility care, per day, for the evaluation and management of a new or
established patient, that requires at least two of these three key components:
-	an expanded problem-focused interval history;
-	an expanded problem-focused examination;
-	medical decision making of moderate complexity
99313	Subsequent nursing facility care, per day, for the evaluation and management of a new or
established patient, that requires at least two of these three key components:
-	a detailed interval history;
-	a detailed examination;
-	medical decision making of moderate to high complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-4	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Service Description
Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services New Patient
99321	Domiciliary or rest home visit for the evaluation and management of a new patient, that requires
these three key components:
-	a problem-focused history;
-	a problem-focused examination; and
-	medical decision making that is straightforward or of low complexity
99322	Domiciliary or rest home visit for the evaluation and management of a patient, that requires these
three key components:
-	an expanded problem-focused history;
-	an expanded problem-focused examination; and
-	medical decision making of moderate complexity
99323	Domiciliary or rest home visit for the evaluation and management of a patient, that requires these
three key components:
-	a detailed history;
-	a detailed examination; and
-	medical decision making of high complexity
Established Patient
99331	Domiciliary or rest home visit for the evaluation and management of an established patient, that
requires at least two of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	medical decision making that is straightforward or of low complexity
99332	Domiciliary or rest home visit for the evaluation and management of an established patient, that
requires at least two of these three key components:
-	an expanded problem-focused interval history;
-	an expanded problem-focused examination;
-	medical decision making of moderate complexity
99333	Domiciliary or rest home visit for the evaluation and management of an established patient, that
requires at least two of these three key components:
-	a detailed interval history;
-	a detailed examination;
-	medical decision making of high complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-5	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Service Description
Home Services New Patient
99341	Home visit for the evaluation and management of a new patient, that requires these three key
components:
-	a problem-focused history;
-	a problem-focused examination; and
-	straightforward medical decision making
99342	Home visit for the evaluation and management of a new patient, that requires these three key
components:
-	an expanded problem-focused history;
-	an expanded problem-focused examination; and
-	medical decision making of low complexity
99343	Home visit for the evaluation and management of a new patient, that requires these three key
components:
-	a detailed history;
-	a detailed examination; and
-	medical decision making of moderate complexity 99345      Home visit for the evaluation and management of a new patient, that requires these three key
components:
-	a comprehensive history;
-	a comprehensive examination; and
-	medical decision making of high complexity
Established Patient
99347	Home visit for the evaluation and management of an established patient, that requires at least two
of these three key components:
-	a problem-focused interval history;
-	a problem-focused examination;
-	straightforward medical decision making
99348	Home visit for the evaluation and management of an established patient, that requires at least two
of these three key components:
-	an expanded problem-focused interval history;
-	an expanded problem-focused examination;
-	medical decision making of low complexity
-	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.3-6	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Service Description
99349	Home visit for the evaluation and management of an established patient, that requires at least two
of these three key components:
-	a detailed interval history;
-	a detailed examination;
-	medical decision making of moderate complexity
99350	Home visit for the evaluation and management of an established patient, that requires at least two
of these three key components:
-	a comprehensive interval history;
-	a comprehensive examination;
-	medical decision making of moderate to high complexity
-	
Commonwealth of Massachusetts
Medical Assistance Program
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.5-1	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
605 Nurse-Midwife Service Codes and Descriptions
See 130 CMR 430.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier.
Service
Code-Modifier   Service Description
T1015-TH	Clinic visit/encounter, all-inclusive – obstetrical treatment/services, prenatal or postpartum
(use for a medical visit with a nurse midwife for a prenatal or postpartum service)
59400	Routine obstetric care, including antepartum care, vaginal delivery (with or without
episiotomy, and/or forceps) and postpartum care
0	Vaginal delivery only (with or without episiotomy and/or forceps)
1	Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care (Hysterectomy Information (HI-1) form required)
59414	Delivery of placenta (separate procedure)
59610	Routine obstetric care including antepartum care, vaginal delivery (with or without
episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery
59612	Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or
forceps)
59614	including postpartum care

Commonwealth of Massachusetts
Medical Assistance Program
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.5-2	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
This page is reserved.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.8-1	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
608   Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions
Service
Code       Service Description
0	Screening test, pure tone, air only
1	Pure tone audiometry (threshold); air only 99173      Screening test of visual acuity, quantitative, bilateral. (Use for titmus vision test.)
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.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
COMMUNITY HEALTH CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6.8-2	

	TRANSMITTAL LETTER
CHC-66	DATE
01/01/03	
This page is reserved.

Attachment 1
TL CHC-66
December 2002
Community Health Center Service Code Crosswalk

Obsolete Code	Obsolete Code Description	New Code -Modifier	New Code Description	Modifier Descr	
X5901	Medical visit w/ nurse midwife for a prenatal or postpartum service	T1015 – TH	Clinic visit/encounter, all-inclusive	Obstetrical treatment/services, prenatal or postpartum	
X5902	Individual medical visit	T1015	Clinic visit/encounter, all-inclusive		
X5903	Individual mental health visit	90899	Unlisted psychiatric service or procedure		
X5904	Group clinic visit	T1015 - HQ	Clinic visit/encounter, all-inclusive	Group setting	
X5580	HIV pre-counseling visit	99402	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes		
X5581	HIV post-counseling visit	99402	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes		
X5582	Urgent care Mon - Fri 5:00 P.M.-6:59 A.M.; Sat 7:00 A.M.-4:00 P.M.	99050	Services requested after office hours in addition to basic services		
X5583	Urgent care 4:01P.M. Sat-6:59 A.M. Mon	99054	Services requested on Sundays and holidays in addition to basic services		
X9335	Titmus vision test	99173	Screening test of visual acuity, quantitative, bilateral