Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

TO:
FROM:
RE:

MASSHEALTH
TRANSMITTAL LETTER CHC-68
September 2003
Community Health Centers Participating in MassHealth Beth Waldman, Acting Commissioner
Community Health Center Manual (Revisions to Service Codes and Descriptions)

This letter transmits revised service codes and descriptions for the Community Health Center Manual. The revised Subchapter 6 is effective for dates of service on or after October 1, 2003.
The Centers for Medicare and Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. 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.
Dental Enhancement Fee
Effective for dates of service on or after October 1, 2003, the MassHealth local service code for the dental enhancement fee (X2003) has been replaced with CDT code D9450 (case presentation, detailed and extensive treatment planning). This code may be billed only on the MassHealth proprietary paper or electronic (EMC) claim form no. 11, or on the HIPAA-complaint 837 Dental transaction. This code may not be billed on the MassHealth proprietary paper/EMC claim form no. 9 or on the 837 Professional transaction. Local Service Code X2003 will not be accepted for dates of service after September 30, 2003.
How to Obtain a 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

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

MASSHEALTH
TRANSMITTAL LETTER CHC-68 September 2003 Page 2
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 6.3-1 through 6.3-6
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Community Health Center Manual
Pages 6.3-1 through 6.3-6 — transmitted by Transmittal Letter-66

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-68	DATE
10/01/03	
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     Service Description
CHC Visits

D9450
X3333 T1015
T1015      HQ 90899 99050
99054
99402
99221
99222
99223

Case presentation, detailed and extensive treatment planning (use only for dental
enhancement fee. This code may only be billed 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.)
Clinic visit/encounter, all-inclusive (Use for individual medical visit.)
Clinic visit/encounter, all-inclusive, group setting (Use for group clinic visit.)
Unlisted psychiatric service or procedure (Use for individual mental health visit.)
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 service
(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.)
Preventive medicine counseling and/or risk factor reduction intervention(s) provided
to an individual (separate procedure); approximately 30 minutes (Use for HIV
counseling visits.)
Hospital Inpatient Services
Initial hospital care, per day, for the evaluation and management of a patient, which 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, which 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, which 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
6.3-1	

	TRANSMITTAL LETTER
CHC-68	DATE
10/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Modifier        Service Description
99431	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.)
Subsequent Hospital Care
99231	Subsequent hospital care, per day, for the evaluation and management of a patient,
which 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,
which 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,
which 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,
which 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,
which 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,
which 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
6.3-2	

	TRANSMITTAL LETTER
CHC-68	DATE
10/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Modifier     Service Description
Nursing Facility Services
99301	Evaluation and management of a new or established patient involving an annual
nursing facility assessment, which 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, which 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, which requires these three key components:

 -	a comprehensive history;
 -	a comprehensive examination; and
 -	medical decision making of moderate to high complexity
Subsequent Nursing Facility Care
99311	Subsequent nursing facility care, per day, for the evaluation and management of a new
or established patient, which 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, which 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, which 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
6.3-3	

	TRANSMITTAL LETTER
CHC-68	DATE
10/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Modifier     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,
which 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, which
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, which
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, which 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, which 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, which 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
6.3-4	

	TRANSMITTAL LETTER
CHC-68	DATE
10/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Modifier     Service Description
Home Services
New Patient
99341	Home visit for the evaluation and management of a new patient, which 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, which 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, which 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, which 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, which
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, which
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
6.3-5	

	TRANSMITTAL LETTER
CHC-68	DATE
10/01/03	
603   Visit Service Codes and Descriptions (cont.)
Service
Code       Modifier     Service Description
99349	Home visit for the evaluation and management of an established patient, which
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, which
requires at least two of these three key components:
 -	a comprehensive interval history;
 -	a comprehensive examination;
 -	medical decision making of moderate to high complexity